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THE 
CASE  HISTORY  SERIES 


CASE  HISTORIES  IN   MEDICINE 

BY 

Richard  C.  Cabot,  M.D. 

Third  edition,  revised  and  enlarged 


DISEASES  OF  CHILDREN 

BY 

John  Lovett  Morse,  M.D. 

Third  edition,  revised  and  enlarged 
Presented  in  two  hundred  Case  Histories 


ONE  HUNDRED   SURGIC.\L  PROBLEMS 

BY 

James  G.  Mumford,  M.D. 
Second  Printing 


CASE  HISTORIES  IN  NEUROLOGY 

BY 

E.  W.  Taylor,  M.D. 

Second  Printing 


CASE  HISTORIES   IN  OBSTETRICS 

BY 

Robert  L.  DeNormandie,  M.D. 

Second  Edition 


DISEASES  OF  WOMEN 

BY 

Charles  M.  Green,  M.D. 

Second  Edition 
Presented  in  one  hundred  and  seventy-three  Case  Histories 


NEUROSYPHILIS 

MODERN   SYSTEMATIC  DIAGNOSIS  AND  TREATMENT 
Presented  in  one  hundred  and  thirty-seven  Case  Histories 

BY 

E.  E.  SouTH.\RD,  M.D.,  Sc.D. 

AND 

H.  C.  Solomon,  M.D. 

Being  Monograph  Number  Two  of  the  Psychopathic  Department  of  the  Boston  State  HospiUl,  Massa- 
chusetts. (Monograph  Number  One  was  A  Point  Scale  for  Measuring  Mental  Ability  by  Robert  M. 
Yerkes,  James  VV.  Bridges  and  Rose  S.  Hardwick.    Published  by  Warwick  and  York.     Baltimore  19 15. J 


SHELL  SHOCK  and  other  NEUROPSYCHIATRIC  PROBLEMS 

Printed  in  five  hundred  and  eighty-nine  Case  Histories 

BY 

E.  E.  Southard,  M.D.,  Sc.D. 

Being  Monograph  Number  Three  of  the  Psychopathic  Department  of  the  Bostc^a  Sute  Hospital, 

Massachusetts 


HORSLEY, 1857-1916 


DEJERIXE,  1S49-1917  VAN   GEHTTCHTEN,  1861-1914 

IN   MEMORIAM 


SHELL-SHOCK 

AND  OTHER 

NEUROPSYCHIATRIC  PROBLEMS 

PRESENTED  IN  FIVE  HUNDRED  AND  OGHTY- 
NINE  CASE  HISTORIES 

FROM  THE 

WAR  LITERATURE,  1914-1 91 8 

BY 

E.  E.  SOUTHARD.  M.D.,  Sc.D. 

Director  (1917-1918),  U.  S.  Army  Neuropsychiatric  Training  School  (Boston  Unit); 
Late  Major,  Chemical  Warfare  Service,  U.  S.  Army;  Bullard  Professor  of  Neuro- 
pathology, Harvard  Medical  School;  Director,  Massachusetts  State  Psychi- 
atric Institute  (of  the  Massachusetts  Commission  on  Mental  Diseases) ; 
Late  President,  American  Medico-Psychological  Association 

WITH  A  BIBLIOGRAPHY  BY 
NORMAN  FENTON.  S.B.,  A.M. 

Sergeant  Medical  Corps,  U.  S.  Army  (Assistant  in  Psychology  to  the  Medical  Director, 

Base  Hospital  117  A.  E.  F.);  late  interne  in  Psychology,  Psychopathic  Department, 

Boston  State  Hospital;  Assistant  in  Reconstruction,  National  Committee  for 

Mental  Hygiene 

AND  AN  INTRODUCTION  BY 

CHARLES  K.  MILLS.  M.D.,  L.LD. 

Emeritus  Professor  of  Neurology,  University  of  Pennsylvania 


BY  VOTE  OF  THE  TRUSTEES  OF  THE  BOSTON  STATE  HOSPITAL 

MONOGRAPH  NUMBER  THREE 

or  THE 

PSYCHOPATHIC  DEPARTMENT 


BOSTON 

W.  M.  LEONARD,  Publisher 
1919 


7a«*«^^t)-'?'f1^ 


COPYRIGHT,     I919,     BY 
W.    M.    LEONARD 


So'i 


Co 

THE  NATIONAL   COMMITTEE   FOR 

MENTAL   HYGIENE 

AND 

ITS   WORK  IN 
WAR   AND   PEACE 


PREFACE 

This  compilation  was  begun  in  the  preparedness  atmos- 
phere of  the  U.  S.  Army  Neuropsychiatric  Training  School 
at  Boston,  191 7-18.  This  particular  school  had  to  adapt 
itself  to  the  clinical  material  of  the  Psychopathic  Hospital. 
Although  war  cases  early  began  to  drift  into  the  wards 
(even  including  some  overseas  material),  it  was  thought 
well  to  supplement  the  ordinary  "acute,  curable,  and  in- 
cipient" mental  cases  of  the  hospital  wards  and  out-patient 
service  with  representative  cases  from  the  literature. 

As  time  wore  on,  this  ''preparedness"  ideal  gave  place 
to  the  ideal  of  a  collection  of  cases  to  serve  as  a  source-book 
for  reconstructionists  dealing  with  neuroses  and  psychoses. 
Shortage  of  medical  staff  and  delays  incidental  to  the  influ- 
enza epidemic  held  the  book  back  still  further,  and,  as  mean- 
time Brown  and  Williams  had  served  the  immediate  need 
with  their  Neuropsychiatry  and  the  War,  it  was  determined 
to  make  the  compilation  the  beginning  of  a  case-history 
book  on  the  neuropsychiatry  of  the  war,  following  In  part 
the  traditions  of  various  case-books  In  law  and  medicine. 

With  the  conclusion  of  the  armistice,  there  is  by  no  means 
an  end  of  these  problems.  Peace-practice  In  neuropsychi- 
atry is  bound  to  undergo  great  changes  and  improvements, 
If  only  from  the  Influx  into  the  peace-community  of  many 
more  trained  neuropsychlatrlsts  than  were  ever  before  avail- 
able. This  is  particularly  true  in  the  American  community 
by  reason  of  the  many  good  men  specially  trained  in  camp 
and  hospital  neuropsychiatry,  both  at  home  and  In  the 
A.  E.  F.,  through  the  enlightened  policy  of  our  army  In 
establishing  special  divisions  of  the  Surgeon-General's  Office 
dealing  separately  with  those  problems. 

Though  a  book  primarily  for  physicians,  some  of  its  mate- 
rial has  interest  for  line-officers,  who  may  see  how  much 
"criming"  is  matter  for  medical  experts,  by  running  through 
the  boxed  headings  (especially  of  Sections  A  and   B)   and 


PREFACE 

reading  the  simulation  cases.  As  Chavigny  remarks,  "  shoot- 
ing madmen  neither  restrains  crime  nor  sets  a  good  example." 

But  parts  of  the  book  look  ahead  to  Reconstructio?i. 
Surely  occupation-workers,  vocationalists,  war  risk  insurance 
experts,  and  in  fact  all  reconstructionists,  medical  and  lay,  must 
find  much  to  their  advantage  in  the  data  of  Section  D  (Treat- 
ment and  Results).  Had  time  permitted,  the  whole  old 
story  of  "Railway  Spine"  — Shell-shock's  congener  —  might 
have  been  covered  in  a  series  of  cases  from  last  centur^^'s 
literature,  together  with  others  illustrating  the  effects  of 
suggestion  and  psychotherapy;  but  this  must  be  a  post- 
bellum  task. 

The  compiler,  who  has  personally  dictated  (and  as  a  rule 
redictated  and  twice  condensed)  all  the  cases  from  the  originals 
(or  in  a  few  instances,  e.g.,  Russian,  from  translations),  hopes 
he  has  not  added  anything  new  to  the  accounts.  The  cases 
are  drawn  from  the  literature  of  the  belligerents,  1914-1917, 
English,  French,  Italian,  Russian,  and  —  so  far  as  available 
here  —  German  and  Austrian. 

I  would  call  the  collection  not  so  much  a  posey  of  other 
men's  flowers  as  a  handful  of  their  seeds.  For  I  have  con- 
stantly not  so  much  transcribed  men's  general  conclusions  as 
borrowed  their  specific  fine-print  and  footnotes.  The  lure 
of  the  100  per  cent  has  been  very  strong  in  many  authors;  but 
the  test  of  fine-print,  viz.,  of  the  actual  case-protocols,  saves 
us  from  premature  conclusions,  and  the  plan  of  the  book 
allows  us  to  confront  actualities  with  actualities.  One  gets 
the  impression  of  a  dignified  debate  from  the  way  in  which 
case-histories  automatically  confront  each  other,  say  in 
Section  C  (Diagnosis). 

Obligations  to  the  books  of  Babinski  and  Froment,  Eder, 
Hurst,  Mott  (Lettsomian  Lectures),  Roussy  and  Lhermitte, 
Elliot  Smith  and  Pear,  and  others  are  obvious.  Yealland's 
book  came  too  late  for  sampling  its  miracles,  though  cases  of 
his  in  the  periodical  literature  had  already  been  incorporated 
in  my  selection. 

Some  of  the  cases  in  Section  A,  i,  had  already  been  ab- 
stracted in  Neurosyphilis:  Modern  Systematic  Diagnosis  and 
Treatment  (Southard  and  Solomon,  191 7). 


PREFACE 

What  we  actually  have  made  is  a  case-history  book  in  the 
newly  combined  fields  now  collectively  termed  neuropsy- 
chiatry. The  more  general  the  good  general  practitioner  of 
medicine,  the  more  of  a  neuropsychiatrist!  And  this  is  no 
pious  wish  or  counsel  of  perfection.  Neuropsychiatry,  men- 
tal hygiene,  psychotherapy  and  somatotherapy — all  these  will 
flourish  intra-bellum  and  post-bellum,  in  days  of  destruction 
and  in  days  of  reconstruction.  And  who  amongst  us,  medical 
or  lay,  will  not  have  to  deal  in  reconstruction  days  with  cases 
like  some  here  compiled  ?  A  minor  blessing  of  the  war  will  be 
the  incorporation  of  mental  hygiene  in  general  medical  prac- 
tice and  in  auxiliary  fields  of  applied  sociology,  e.g.,  medi- 
co-social work. 

Subsidies  aiding  publication  are  due  to  the  National 
Committee  for  Mental  Hygiene;  the  Permanent  Charity 
Foundation  (Boston  Safe  Deposit  and  Trust  Company); 
Mrs.  Zoe  D.  Underbill  of  New  York;  Mr.  H.  T.  White  of 
New  York;  and  Dr.  W.  N.  BuUard  of  Boston — to  all  of 
these  the  various  military  recipients  of  the  book  will  be  under 
obligations,  as  well  as  others  who  would  otherwise  have  had 
to  pay  the  great  maj oration  de  prix  due  to  war  times. 

Of  those  great  dead  contributors  to  neurology  laid  (in  the 
Epicrisis)  at  the  feet  of  the  neo-Attila,  perhaps  only  Sir 
Victor  was  in  a  narrow  sense  the  Kaiser's  victim:  still,  but 
for  the  war,  they  might  all  remain  to  us. 

By  the  way,  just  as  I  found  John  Milton  had  said  things 
that  fitted  neurosyphilis,  so  also  Dante  is  observed  in  the 
chosen  mottoes  to  have  had  inklings  even  of  Shell-shock. 
To  the  Inferno  it  was  natural  to  turn  for  fitting  mottoes 
(Carlyle's  renderings  mainly  used).  The  pages  might  have 
been  strewn  with  them.  A  glint  of  too  great  optimism  might 
seem  to  shine  — in  the  pre-Epicrisis  motto  — from  the  lance  of 
Achilles  with  its  "sad  yet  healing  gift ; "  but  out  of  Shell-shock 
Man  may  get  to  know  his  own  mind  a  little  better,  how  under 
stress  and  strain  the  mind  lags,  blocks,  twists,  shrinks,  and 
even  splits,  but  on  the  whole  is  afterwards  made  good  again. 

E.  E.  Southard. 

Washington, 
November^  1918. 


INTRODUCTION 

The  duties  of  an  introducer,  whether  of  a  platform  speaker 
to  an  audience,  or  of  a  writer  to  his  anticipated  readers,  are  not 
always  clearly  defined.  It  has  been  sometimes  said  that  the 
critic  or  reviewer  may  meet  with  better  success  if  he  has  not 
acquainted  himself  too  thoroughly  with  the  contents  of  the 
book  about  which  he  writes,  as  in  that  case  he  will  have  a  larger 
opportunity  to  indulge  his  imagination,  but  a  critique  thus  pro- 
duced may  have  the  disadvantage  of  possible  shortcoming  or 
unfairness.  In  the  case  of  this  volume,  however,  I  have  felt  it 
worth  while  to  acquaint  myself  with  its  contents,  no  light  task 
when  one  is  confronted  with  a  thousand  pages. 

The  great  war  just  closing  has  done  much  to  enlighten  us  as 
to  the  causes,  nature,  outcome,  and  treatment  of  injuries  and 
diseases  to  which  its  victims  have  been  subjected.  The  object 
of  this  book  is  to  present  both  the  data  and  the  principles  in- 
volved in  certain  neuropsychiatric  problems  of  the  war.  These 
are  presented  in  a  wealth  of  detail  through  an  extraordinary 
series  of  case  records  (589  in  all)  drawn  from  current  medical 
Hterature,  during  the  first  three  years  of  the  conflict.  Case 
reporting  is  here  seen  at  its  best,  and  the  experiences  re- 
corded are  largely  allowed  to  speak  for  themselves,  although 
comments  are  not  wanting  and  are  often  illuminating. 

Many  criticisms  have  been  heard  on  the  use  of  the  term  Shell- 
shock  as  applied  to  some  of  the  most  important  psychiatric  and 
neurological  problems  of  the  recent  war;  but  that  the  designa- 
tion has  meaning  will  be  evident  if  Dr.  Southard's  book  is  not 
simply  skimmed  over  by  the  reader,  but  is  studied  in  its  entirety. 
The  symptoms  of  a  very  large  number,  if  not  the  majority,  of 
the  cases  recorded,  had  for  their  initiating  influence  the  psychic 


VI  INTRODUCTION 

and  physical  horrors  of  life  among  exploding  shells.  As  the 
author  and  those  from  whom  he  has  received  his  clinical  supply 
not  infrequently  point  out,  in  many  cases  it  would  appear  that 
purely  psychic  influences  have  played  the  chief  role,  but  in  others 
physical  injuries  have  not  been  lacking.  Much  more  than  this 
is  true:  in  many  instances  the  soil  was  prepared  by  previous 
defect,  disease,  or  injury,  or  to  use  one  of  Dr.  Southard's  favorite 
expressions,  "weak  spots"  were  present  before  martial  causes 
became  operative. 

While  the  contributions  to  the  medical  and  surgical  history  of 
the  war  have  been  somewhat  numerous  in  current  medical  jour- 
nals and  in  monographs,  few  comprehensive  volumes  have  ap- 
peared. The  reasons  for  this  are  not  far  to  seek.  The  conflict 
has  been  of  such  magnitude,  and  the  demands  on  the  bodily  and 
mental  activity  of  the  medical  profession  have  been  so  intense 
and  continuous,  that  time  and  opportunity  for  the  careful  and 
complete  recording  of  experiences  have  not  been  often  available; 
but  works  are  beginning  to  appear  in  the  languages  of  all  the 
belligerent  countries  and  these  will  increase  in  number  and 
value  during  the  next  lustrum  and  decade,  although  it  may  be 
that  some  of  the  most  important  contributions  will  come  after  a 
decade  or  more  is  past.  The  great  work  before  me  is  one  that 
will  leave  its  lasting  impress,  not  only  upon  miHtary  but  on  civil 
medicine,  for  the  lessons  to  be  drawn  from  its  pages  are  in  large 
part  as  applicable  to  the  one  as  to  the  other. 

Looking  backward  to  our  Civil  War,  one  is  strongly  impressed 
with  the  fact  that  the  present  volume,  one  of  the  earliest  works 
of  its  kind  to  appear  in  book  form,  deals  largely  with  psychiatry 
and  functional  ners^ous  diseases,  whereas  during  and  after  the 
American  conflict  the  most  important  contributions  to  neurology 
related  to  organic  disease,  especially  as  illustrated  by  the  work 
of  Weir  Mitchell  and  his  collaborators  on  injuries  of  nerves. 
This  is  the  more  interesting  when  it  is  remembered  that  Mitchell 
not  very  long  after  the  close  of  the  Civil  War  became  the  most 
prominent  exponent  of  functional  neurology,  from  the  diagnostic 


INTRODUCTION  Vll 

and  therapeutic  sides.  To  him  the  profession  the  world  over  has 
been  indebted  for  the  development  of  new  views  as  to  the  nature 
of  neurasthenia  and  hysteria  and  new  methods  for  combating 
these  disorders.  In  this  fact  is  to  be  found  matter  for  thought. 
Those  who  handled  best  the  neuropsychiatric  problems  of  the 
present  war  were  in  large  part  quahfied  not  merely  by  a  knowl- 
edge of  psychology  and  psychiatry,  but  far  more  by  a  thorough 
training  in  organic  neurology.  The  problems  of  psychiatry  can 
be  grasped  fully  only  by  those  who  have  a  fundamental  knowl- 
edge of  the  anatomy,  physiology,  and  diseases  of  the  nervous 
system. 

Dr.  Southard,  preeminently  a  neuropathologist,  is  well 
grounded  in  organic  neurology,  and  shows  at  every  turn  his 
capabiUties  for  considering  the  neuroses,  psychoses,  and  insani- 
ties from  the  standpoint  of  the  neurologist.  Moreover,  he 
clearly  shows  training  and  insight  into  the  problems  of  non- 
neurological  internal  medicine. 

The  ideal  method  of  training  a  student  for  neuropsychiatric 
work  —  if  one  had  the  opportunity  of  directing  his  course 
from  the  time  of  his  entry  into  medicine  —  would  be  to  see  to 
it,  after  a  good  grounding  in  the  fundamental  sciences  like 
anatomy,  physiology,  and  chemistry,  that  medicine  and  surgery 
in  their  broadest  phases  first  received  school  and  hospital  atten- 
tion; that  the  fields  of  neurology,  pure  and  applied,  were  then 
fully  explored;  and  that  psychology  and  psychiatry  received  late 
but  thorough  consideration.  When  after  America's  entrance  into 
the  world  war  the  writer  assisted  in  preparing  medical  reserve 
officers  for  neuropsychiatric  service,  those  men  did  best  both 
during  their  postgraduate  work  and  in  base  hospitals  and  in 
the  field,  who  had  built  from  the  bottom  after  the  manner  in- 
dicated. 

At  the  outset  of  Dr.  Southard's  book,  for  more  than  two  hun- 
dred and  fifty  pages,  the  author  considers  under  ten  subdivisions 
the  acquired  diseases  and  constitutional  defects  which  may  pre- 
dispose  the   soldier   to   functional   and   reflex   nervous   disease. 


vill  INTRODUCTION 

Neurosyphilis,  on  which  Dr.  Southard  and  Dr.  Solomon  have 
already  given  us  a  valuable  treatise,  the  pharmacopsychoses, 
especially  alcohoUsm,  and  the  somatopsychoses  covering  fevers 
like  typhoid  and  paratyphoid,  are  considered  in  numerous  care- 
fully chosen  case  reports.  The  reader  needs  only  to  look  closely 
into  the  case  records  of  the  first  quarter  of  the  volume  to  get  a 
knowledge  of  the  affections  chiefly  predisposing  the  soldier  or 
civilian  to  functional  and  reflex  nervous  diseases.  To  those 
familiar  with  the  medical  history  of  the  war  it  is  well  known 
that  one  of  the  reasons  for  the  efficiency  of  the  American  Ex- 
peditionary Force  resided  in  the  fact  that  the  preliminary 
examinations  of  the  recruits  received  the  fullest  attention  not 
only  from  the  points  of  view  of  acquired  and  inherited  disease, 
but  also  from  those  of  special  psychiatric  and  even  psychological 
deficiencies.  Our  country,  however,  had  for  its  guidance  the 
experience  of  nations  which  were  fighting  for  three  years  before 
we  entered  the  arena  and  in  addition  had  a  large  surplus  of 
material  from  which  to  cull  out  the  weaklings. 

Among  the  predispositional  affections  considered  —  besides 
syphilis,  alcohol,  and  other  drug  habits,  and  the  somatopsychoses 
—  are  the  feeble-mindednesses  or  hypophrenoses,  the  epilepsies, 
the  psychoses  due  to  focal  brain  lesions,  the  presenile  and  senile 
disorders,  the  schizophrenoses  including  dementia  praecox  and 
alHed  affections,  the  cyclothymoses  Hke  manic  depressive  insan- 
ity, the  psychoneuroses,  and  the  psychopathoses.  The  last  two 
subjects  indicated,  considered  in  special  chapters,  seem  to  some 
extent  to  be  receptacles  for  affections  which  cannot  well  be 
otherwise  placed,  —  hallucinoses,  hysteria,  neurasthenia,  and  psy- 
chasthenia,  —  and  under  the  psychopathoses,  pathological  lying, 
Bolshevism,  definquencies  of  various  sorts,  homosexuality,  suicide 
and  self-mutilation,  nosophobia,  and  even  claustrophobia  with 
its  exemplar  who  preferred  exposure  to  shell-fire  to  remaining  in 
a  tunnel. 

Under  the  encephalopsychoses  are  found  interesting  illustra- 
tions of  focal  lesions  and  the  general  effects  of  infection  and 


INTRODUCTION  IX 

toxemia.  Cases  of  brain  abscess,  of  spinal  focal  lesions,  and 
meningeal  hemorrhage  are  in  evidence,  aphasias,  monoplegias, 
Jacksonian  spasm,  and  thalamic  disease  receiving  consideration. 

All  neurologists  know  the  dijQ&culties  in  diagnosticating  epilepsy 
in  the  absence  of  opportunities  to  see  attacks  and  to  receive  the 
carefully  analyzed  statement  of  the  observers  of  the  patient. 
All  this  and  much  more  is  well  brought  out  in  the  chapter  on  the 
epileptoses.  Many  epileptics  found  their  way  into  the  armies 
either  through  the  carelessness  of  examiners  or  by  suppression  of 
the  facts  on  the  part  of  those  who  desired  to  serve. 

The  fact  that  an  imbecile  can  shoot  straight  and  face  fire 
comes  out  in  one  or  two  places,  but  this  does  not  seem  to  prove 
that  a  good  rifleman  is  necessarily  an  all-round  good  soldier. 

A  book  like  Dr.  Southard's  could  be  made  of  much  use  in 
teaching  students,  especially  postgraduates,  by  having  them, 
when  a  particular  subject  like  epilepsy  or  schizophrenia,  for  in- 
stance, is  under  discussion,  use  as  collateral  reading  the  case 
reports  of  this  work. 

Dr.  Southard's  book  will  prove  useful  to  many  workers  —  to 
the  medical  officer  whose  duty  it  is  to  examine  recruits  for  the 
service  or  to  pass  upon  and  treat  them  while  in  service;  almost 
equally  to  the  medical  officer  in  time  of  peace;  to  authors  of  text- 
books and  treatises  and  to  contributors  to  neurological  and  psy- 
chiatric journals;  to  lecturers  and  clinical  demonstrators;  to 
the  examiner  for  the  juvenile  courts;  and  to  members  of  the 
psychopathic,  psychiatric,  and  neurological  staffs  of  our 
hospitals. 

One  is  not  called  upon  in  an  introduction  to  review  at  length 
the  contents  of  the  volume,  but  it  may  prove  of  value  to  the 
reader  to  dip  here  and  there  into  the  pages  of  the  work  to  which 
his  attention  is  being  invited. 

It  will  be  remembered  that  fifty  years  ago  and  much  later, 
down  to  the  time  of  Babinski's  active  propaganda  in  favor  of 
the  theories  of  suggestion,  counter-suggestion,  and  persuasion  in 
hysteria,   various  affections   of  a  vasomotor  and   thermic  type 


X  INTRODUCTION 

were  included  in  the  list  of  hysterical  phenomena.  These  and 
some  other  phenomena  sometimes  classed  as  hysterical,  Babinski 
and  those  who  accord  with  him  now  find  it  necessary  to  sweep 
entirely  from  the  domain  of  hysteria,  which  being  produced  by 
suggestion  and  cured  by  counter-suggestion  or  persuasion  cannot 
include  symptoms  which  are  beyond  the  control  of  the  will  and 
intellect  of  the  patient. 

According  to  the  new  or  rather  revived  pronouncement,  these 
must  be  due  either  to  definite  organic  lesion,  or  to  a  disorder  of 
reflex  origin,  connoting  the  occurrence  of  changes  in  the  nervous 
centers  as  long  ago  taught  by  Vulpian  and  Charcot.  In  the 
records  of  cases  and  in  the  discussions  thereon  this  differentia- 
tion receives  much  consideration. 

It  is  held  that  the  paralysis  in  the  reflex  cases  is  more  limited, 
more  persistent,  and  assumes  special  forms  not  observable  in 
hysteria.  The  attitudes  in  hysterical  palsies  conform  more  to 
the  natural  positions  of  the  limbs  than  do  those  observed  in 
reflex  paralysis.  Probably  the  presence  of  marked  amyotrophies 
in  the  reflex  nervous  disorders  is  the  most  comdncing  factor  in 
separating  these  from  pithiatic  affections.  These  atrophies  cor- 
respond to  the  arthritic  muscular  atrophies  of  Vulpian,  Charcot, 
Gowers,  and  others,  and  cannot  for  a  moment  be  regarded  as 
caused  by  suggestion  or  as  removable  by  counter-suggestion  or 
persuasion.  They  are  influenced,  discounting  the  effect  of  time 
and  natural  recuperation,  only  by  methods  of  treatment  de- 
signed to  improve  the  peripheral  and  central  nutrition  of  the 
patient.  Pithiatic  atrophies  are  slight  and  probably  always  to 
be  accounted  for  by  disuse  or  the  association  of  some  peripheral 
neural  disorder  with  the  hysteria.  Affections  of  the  sudatory 
and  pilatory  systems  are  more  definitely  pronounced  in  reflex 
cases  than  in  those  of  a  strictly  hysterical  character. 

Some  of  the  facts  brought  forward  by  Babinski  and  Froment 
to  demonstrate  the  differentiation  of  reflex  paralyses  from  pithia- 
tic disorders  of  motion  are  challenged  in  the  records  of  this 
volume  by  others,  as  for  instance,  by  Dejerine,  Roussy,  Marie, 


INTRODUCTION  XI 

and  Guillain.  Babinski  tells  us  that  in  pithiatism,  properly  so 
designated,  the  tendon  reflexes  are  not  affected.  He  believes 
that  even  in  pronounced  anesthesia  of  the  lower  extremities  the 
plantar  reflexes  can  always  be  ehcited  and  are  not  abnormal  in 
exhibition.  Dejerine,  however,  produces  cases  to  illustrate  the 
fact  that  in  marked  hysterical  anesthesia  of  the  feet  plantar 
responses  cannot  be  produced.  I  have  personally  studied  cases 
which  lend  some  strength  to  either  contention.  In  some  of 
these  I  was  not  able  to  conclude  that  either  the  use  of  the  will 
or  the  presence  of  contractions  in  extension  was  sufficient  to 
exclude  the  normal  responses. 

Differences  in  muscle  tonicity,  in  mechanical  irritability  of 
the  muscles,  and  the  presence  or  absence  of  fibrotendinous  con- 
tractions are  indications  of  a  separation  between  the  reflex  and 
purely  functional  cases,  as  apparently  demonstrated  in  some  of 
the  case  records.  True  trophic  disorders  of  the  skin,  hair,  and 
bones  observed  in  the  reflex  cases  are  also  said  to  have  no  place 
in  the  illustrations  of  pithiatism. 

The  delver  into  the  case  histories  of  this  volume  will  find  nu- 
merous instructive  combinations  of  hystero-reflex  and  organo- 
hysterical  associations  which  are  not  to  be  enumerated  in  an 
introduction.  The  great  importance  of  what  all  recognize  as 
pathognomonic  signs  of  organic  disease  —  Babinski  extensor  toe 
response,  persistent  foot  clonus,  reactions  of  degeneration, 
marked  atrophy,  lost  tendon  jerks,  etc.  —  is,  of  course,  continu- 
ously in  evidence.  Extraordinary  associations  of  hysterical, 
organic,  and  reflex  disorders  with  other  affections  due  to  direct 
involvement  of  bone,  muscle,  and  vessels  and  with  the  second- 
ary effects  of  cicatrization  and  immobilization  are  brought  out 
on  many  pages.  In  quitting  this  branch  of  our  subject  it  might 
be  remarked  that  considerable  changes  must  be  made  in  our 
textbook  descriptions  of  nervous  diseases  in  the  light  of  the  con- 
tributions to  the  neurology  of  the  present  war. 

One  is  reminded  in  the  details  of  some  of  the  cases  of  the  dis- 
cussions some  decades  since  on  the  subject  of  spinal  traumatisms; 


XU  INTRODUCTION 

of  the  work  of  Erichsen  which  resulted  in  giving  his  name  and 
that  of  "railway  spine"  to  many  of  the  cases  now  commonly 
spoken  of  as  traumatic  hysteria  and  traumatic  neurasthenia;  of 
the  rejoinders  of  Page  and  his  views  regarding  spinal  trauma- 
tisms; and  of  Oppenheim's  development  of  the  symptom  com- 
plex of  what  he  prefers  to  term  the  traumatic  neurosis.  One 
who  has  taken  part  in  much  court  work  cannot  but  read  these 
case  records  with  interest,  for  the  neurology  of  the  war  as  pre- 
sented in  this  volume  and  in  numerous  monographs  which  are 
now  appearing,  throws  much  light  upon  many  often  mooted 
medicolegal  problems.  I  recall  how  many  able  and  honest  neu- 
rological observers  have  changed  their  points  of  view  since  the 
early  days  of  Erichsen's  "railway  spine,"  a  pathological  sugges- 
tion which  is  said  to  have  cost  the  corporations  of  England  an 
almost  fabulous  sum  during  a  score  of  years.  I  recall  also  that 
a  certain  Court  of  Appeals  in  one  of  our  states  even  felt  itself 
called  upon  to  promulgate  an  opinion  intended  to  exorcise  en- 
tirely the  plea  for  damages  for  alleged  injuries  if  it  could  be 
shown  that  these  were  due  to  fright.  The  data  of  this  book  do 
not  put  weapons  entirely  into  the  hands  of  the  attorney  and 
the  expert  for  either  the  plaintiff  or  the  defendant. 

Some  of  the  French  writers  on  the  neurology  of  the  war,  as 
illustrated  in  the  records  collected  by  Dr.  Southard,  have  brought 
to  our  attention  distinctions  which  they  draw  between  etats 
commotionnels  and  etats  emotion7iels  —  happy  terms,  and  yet  not 
sufficient  in  their  invention  or  in  the  explanations  which  ac- 
company them,  fully  to  satisfy  the  requirements  of  the  facts 
presented.  These  writers  seem  to  think  of  the  commotional 
states  as  denoting  some  real  disease  or  condition  of  the  brain, 
and  yet  one  which  is  really  curable  and  reversible.  They  ex- 
pUcitly  tell  us,  however,  that  these  commotions  fall  short  of 
being  lesionneL  After  all,  is  this  not  somewhat  obscure?  Is  it 
not  something  of  a  return  to  the  period  of  "railway  spine" 
when  one  of  the  comparisons  sometimes  made  was  that  the 
injury  suffered  by  the  nervous  tissues  produced  in  them  a  state 


INTRODUCTION  XIU 

comparable  to  that  of  a  magnet  which  had  been  subjected  to  a 
severe  blow?  At  any  rate,  in  commotion  thus  discussed  the 
nervous  structures  are  supposed  to  sustain  some  real  injury  of  a 
physiochemical  character,  whereas  in  the  emotional  states  the 
neurones  are,  as  Southard  puts  it,  affected  somewhat  after  the 
manner  of  normal  emotional  functioning,  except  perhaps  that 
they  are  called  upon  to  deliver  an  excessive  stream  of  impulses. 
The  latter  would  be  classed  among  the  psychopathic,  the  former 
among  the  physiopathic  affections,  and  yet  the  distinction  be- 
tween the  two  is  not  always  quite  clear. 

In  not  a  few  instances  of  Shell-shock  —  although  these  are 
not  numerous,  so  far  as  records  have  been  obtained  —  actual 
structural  lesions  have  been  recorded  even  in  cases  in  which  no 
direct  external  injury  of  a  material  kind  was  experienced  as  a 
result  of  the  explosion  of  shells.  In  others  the  evidences  of 
external  injury  were  relatively  unimportant.  Various  lesions,  in 
some  cases  recognizable  even  by  the  naked  eye,  were  present. 
Mott,  for  example,  found  not  only  minute  hemorrhages,  but  in 
one  instance  a  bulbar  extravasation  of  moderate  massiveness, 
the  patient  not  showing  external  signs  of  injury.  Cases  are  also 
recorded  of  hematomyelia;  others  with  edematous  or  necrotic 
areas  in  the  cord;  and  still  others  with  lesions  of  the  ependyma 
or  even  with  splitting  of  the  spinal  canal,  reminding  one  of  the 
classical  experiments  of  Duret  on  cerebral  and  cerebrospinal 
traumatisms. 

It  has  been  argued  that  too  much  stress  should  not  be  laid 
on  a  few  cases  of  this  sort  —  but  are  they  as  few  as  they  seem 
to  be?  The  fact  is  that  necropsical  opportunities  are  not  often 
afforded.  May  not  such  scattered  lesions  often  be  present  with- 
out resulting  in  death  or  even  in  long  continued  disturbance? 
There  is  no  essential  reason  why  minute  hemorrhages  into  the 
brain  and  spinal  cord,  and  especially  into  their  membranes,  may 
not  undergo  rapid  absorption  or  even  remain  unchanged  for 
some  time  without  dire  results. 

One  of  the  reported  cases  in  which  lung  splitting  occurred  from 


XIV  INTRODUCTION 

severe  concussion  without  external  injury'  is  not  without  interest 
in  this  connection,  reminding  one,  as  the  commentator  says,  of 
those  cases  of  severe  concussion  in  which  the  interior  of  a  build- 
ing is  injured  while  the  exterior  escapes.  In  the  same  connec- 
tion also  the  cited  experiments  of  Mairet  and  Durante  on  rabbits 
are  not  without  instructiveness.  As  a  result  of  explosives  set  oflf 
close  to  these  animals,  pulmonary  apoplexy,  spinal  cord  and  root 
hemorrhages,  and  extravasations,  perivascular  and  ependymal, 
and  into  the  cortical  and  bulbar  gray  were  found.  Russca  ob- 
tained direct  and  contrecoup  brain  lesions,  etc.,  in  a  similar  way. 

Here  and  there  throughout  the  book  will  be  found  references 
to  s^Tnptoms  and  syndromes  which  will  have  a  particular  inter- 
est for  the  reader  —  soldier's  heart,  trench  foot,  congealed  hand, 
tics,  tremors,  convulsions,  sensory  areas  variously  mapped,  and 
forms  of  local  tetanus,  the  last  being  distinctly  to  be  differen- 
tiated from  pithiatic  contractures  and  those  due  to  organic 
lesions  of  the  nervous  system.  Cases  of  an  affection  described 
by  Souques  as  camptocormia,  from  Greek  words  meaning  to 
bend  the  trunk,  were  shown  to  the  Neurological  Society  of  Paris 
in  1 9 14  and  later,  the  main  features  of  this  affection  being  pro- 
nounced incurvation  forward  of  the  trunk  from  the  dorsolumbar 
region,  with  extreme  abduction  and  outward  rotation  of  the 
lower  limbs,  pain  in  the  back,  and  difficult  and  tremulous  walk- 
ing. In  some  of  these  cases,  organic  lesions  of  the  trunkal  tissues 
were  present,  but  in  addition  psychic  elements  played  a  not  un- 
important part,  and  the  cases  were  restored  to  health  by  a  com- 
bination of  physical  measures  with  psychotherapy,  enforced  by 
electrical  applications. 

The  part  of  this  book  given  over  to  the  discussion  of  treat- 
ment will  doubtless  to  some  prove  the  most  interesting  section. 
The  presentation  of  the  subject  of  therapeutics  is  in  some  degree 
a  discussion  also  of  diagnosis  and  prognosis;  and  so  it  happens  in 
various  parts  of  the  volume  that  the  particular  subject  under 
consideration  is  more  or  less  a  reaffirmation  or  anticipation  of 
remarks  under  other  headings. 


INTRODUCTION  XV 

Similar  results  are  brought  about  by  various  therapeutic  pro- 
cedures. Nonne,  Myers,  and  a  few  others  bring  hypnosis  into 
the  foreground,  although  non-hypnotic  suggestion  plays  a  larger 
role  by  far. 

Miracle  cures  are  wrought  through  many  pages.  Mutism, 
deafness  and  bhndness,  palsies,  contractures,  and  tics  disappear 
at  times  as  if  by  magic  under  various  forms  of  suggestion.  Ether 
or  chloroform  narcosis  drives  out  the  malady  at  the  moment 
when  it  reveals  its  true  nature.  Verbal  suggestion  has  many 
adjuvants  and  collaborators  —  electricity,  sometimes  severely 
administered,  lumbar  puncture,  injections  of  stovaine  into  the 
cerebrospinal  fluid,  injections  of  saline  solution,  colored  lights, 
vibrations,  active  mechanotherapy,  hydrotherapy,  hot  air  baths 
and  blasts,  massage,  etc.  Painful  and  punitive  measures  have 
their  place  —  one  is  inclined  to  think  a  less  valuable  place  than 
is  given  them  by  some  of  the  recorders.  In  some  instances  the 
element  of  suggestion,  while  doubtless  present,  is  overshadowed 
by  the  material  methods  employed.  Persuasion  and  actual 
physical  improvement  are  in  these  cases  highly  important.  Re- 
education is  not  infrequently  in  evidence.  The  patient  in  one 
way  or  another  is  taught  how  to  do  things  which  he  had  lost 
the  way  of  doing. 

It  is  interesting  to  American  neurologists  to  note  how  fre- 
quently in  the  reports,  especially  of  French  observers,  the  "Weir 
Mitchell  treatment"  was  the  method  employed,  including  isola- 
tion, the  faradic  current,  massage,  and  Swedish  movements,  hydro- 
therapy, dietetic  measures,  reeducative  processes,  and  powerful 
suggestion  variously  exhibited,  especially  through  the  mastery 
of  the  physician  over  the  patient.  It  is  rather  striking  that  few 
records  of  Freudian  psychoanalytic  therapy  are  presented. 

When  all  is  said,  however,  counter-suggestion  and  persuasion, 
in  whatever  guise  made  use  of,  were  not  always  sufficient  and 
this  not  only  in  the  clearly  organic  cases,  but  in  those  which  are 
ranked  under  the  head  of  reflex  nervous  disorders.  In  these  the 
long-continued  use  of  physical  agencies  was  found  necessary  to 


XVi  INTRODUCTION 

supplement  the  purely  psychic  procedures,  these  facts  some- 
times giving  rise  in  the  Paris  Society  of  Neurology  and  elsewhere 
to  animated  discussion  as  to  the  real  nature  of  the  cases.  The 
pithiatic  features  of  the  case  at  times  disappear,  but  leave  be- 
hind much  to  be  explained  and  more  to  be  accompHshed.  The 
cures  wrought  are  not  always  permanent  and  in  some  cases  post- 
bellum  experiences  may  be  required  to  prove  the  real  value  of 
the  measures  advocated.  The  reader  must  study  well  the  de- 
tailed records  in  order  to  arrive  at  just  conclusions;  neverthe- 
less, the  tremendous  efficacy  of  suggestion  and  persuasion  stands 
out  in  many  of  the  recitals. 

Perhaps  the  author  may  permit  the  introducer  a  little  Hberty 
of  comment.  His  non-Enghsh  interpellations,  especially  Latin 
and  French,  may  be  regarded  by  some  as  overdone  or  perhaps 
pedantic,  but  are  rather  piquant,  giving  zest  to  the  text.  Diagno- 
sis per  exclusiojiem  in  ordine  is  sonorous  and  has  a  scholarly 
flavor,  but  does  not  prevent  the  reader  who  lives  beyond  the 
faubourgs  of  Boston  from  understanding  that  the  author  is  speak- 
ing of  an  ancient  and  well-tried  method  of  differential  diagnosis. 
Passim  may  be  more  impressive  or  thought-fixing  than  its  EngUsh 
translation,  but  this  to  the  reader  will  simply  prove  a  matter  of 
individual  opinion.  Psychopathia  martialis  is  not  only  mouth- 
filling  like  Senega?nbia  or  Mesopotamia,  but  really  has  a  claim  to 
appreciation  through  its  evident  applicability.  It  is  agreeable 
to  note  that  the  book  seems  nowhere  to  indicate  that  psycho- 
pathia sexiialis  and  psychopathia  martialis  are  convertible  terms. 

The  bibliography  of  the  volume  challenges  admiration  because 
of  its  magnitude  and  thoroughness  and  is  largely  to  be  credited, 
as  the  author  indicates,  to  the  energy  and  efficiency  of  Sergeant 
Norman  Fenton,  who  did  the  work  in  connection  with  the  Neu- 
ropsychiatric  Training  School  at  Boston,  resorting  first-hand  to 
the  Boston  Medical  Library  and  the  Library  of  the  New  York 
Academy  of  Medicine.  After  Sergeant  Fenton  joined  the  Ameri- 
can Expeditionary  Force,  Dr.  Southard  greatly  increased  the 
value  of  the  bibliography  by  his  personal  efforts. 


INTRODUCTION  XVll 

This  bibliography  covers  not  only  the  589  case  histories  of  the 
book,  but  it  goes  beyond  this,  especially  in  the  presentation  of 
references  for  1917,  1918,  and  even  1919.  Owing  to  the  time 
when  our  country  entered  the  war,  American  references  are,  in 
the  main,  of  later  date  than  the  case  histories.  They  will  be 
found  none  the  less  of  value  to  the  student  of  neuropsychiatric 
problems. 

The  references  in  the  bibliography  number  in  all  more  than 
two  thousand,  distributed  so  far  as  nationaUties  are  concerned 
about  as  given  below,  although  some  mistakes  may  have  crept 
into  this  enumeration  for  various  reasons,  like  the  publication  of 
the  same  articles  in  the  journals  of  different  countries.  The  Hst 
of  references  includes  French,  895;  British  (English  and  Co- 
lonial), 396;  ItaHan,  77;  Russian,  100;  American,  253;  Spanish, 
5;  Dutch,  5;  Scandinavian,  5;  and  Austrian  and  German,  476. 
It  will  be  seen,  therefore,  that  the  bibliography  covers  in  number 
nearly  four  times  the  collected  case  studies,  most  of  these  records 
being  from  reports  made  during  the  first  three  years  of  the  war. 
The  author  has  wisely  made  an  effort  to  bring  the  bibliographic 
work  up  to  and  partially  including  19 19. 

The  manner  in  which  the  French  neurologists  and  alienists 
continued  their  work  during  the  strenuous  days  of  the  terrible 
conflict  is  worthy  of  all  praise.  The  labors  of  the  Society  of 
Neurology  of  Paris  never  flagged,  its  contributions  in  current 
medical  journals  having  become  familiar  to  neurologists  who 
have  followed  closely  the  trend  of  medical  events  during  the 
war.  Cases  and  subjects  were  also  frequently  presented  and 
discussed  at  the  neurological  centers  connected  with  the  French 
and  allied  armies  in  France. 

It  may  be  almost  invidious  to  specify  names,  the  work  done 
by  many  was  of  so  much  interest  and  value.  Dejerine  in  the 
early  days  of  the  war,  before  his  untimely  sickness  and  death, 
contributed  his  part.  Marie  from  the  beginning  to  the  end  of 
the  conflict  continued  to  make  the  neurological  world  his  debtor. 
The   name   of   Babinski   stands   out   in   striking   relief.     Other 


XVlll  INTRODUCTION 

names  frequently  appearing  among  the  French  contributors  are 
those  of  Froment,  Clovis  Vincent,  Roussy  and  Lhermitte,  Leri, 
Guillain,  Souques,  Laignel-Lavastine,  Courbon,  Grasset,  Claude, 
Barre,  Benisty,  Foix,  Chavigny,  Charpentier,  Meige,  Thomas, 
and  Sollier. 

For  a  work  of  this  character  not  only  as  complete  a  bibliog- 
raphy as  possible,  but  a  thorough  index  is  absolutely  necessary, 
and  this  has  been  suppUed.  The  author  has  not  made  the  index 
too  full,  but  with  enough  cross-references  to  enable  those  in  all 
lines  of  medical  work  interested  to  cull  out  the  cases  and  com- 
ments which  most  concern  them. 

My  prologue  finished,  I  step  aside  for  the  play  and  the  player, 
with  the  recommendation  to  the  reader  that  he  give  close  heed 
to  the  performance  —  to  the  recital  of  the  cases,  the  comments 
thereon,  and  the  general  discussion  of  subjects  —  knowing  that 
such  attention  will  be  fully  rewarded,  for  in  this  wonderful  col- 
lection of  Dr.  Southard  is  to  be  seen  an  epitome  of  war  neurology 
not  elsewhere  to  be  found. 

Charles  K.  Mills. 

Philadelphia,  May,  19 19. 


TABLE   OF    CONTENTS 

SECTION  A.     PSYCHOSES  INCIDENTAL  IN  THE  WAR 

I.  The  Syphilitic  Group  {Sypkilopsychoses) 

Case  Page 

1.  Desertion  of  an  officer Briand,  1915 ....  8 

2.  Visions  of  a  naval  officer Carlill,  Fildes,  Baker,  1917 ....   9 

3.  Aggravation  of  neuros3TphiJis  by  war  Weygandt,  1915 ....  10 

4.  Same Hurst,  1917 . ...  10 

5.  Same Beaton,  1915 ....  10 

6.  Same Boncherot,  1915 ....  11 

7.  Same Todd,  1917. . .  .12 

8.  Same Farrar,  191 7 ....  13 

9.  Same Marie,  Chatelin,  Patrikios,  1917 . ...  14 

10.  Root-sciatica Long,  1916. . .  .15 

II.  Disciplinary Kastan,  1916.  ...  17 

12.  Same Kastan,  1916.  . .  .18 

13.  Same? Kastan,  1916. . .  .19 

14.  Hysterical  chorea  versus  neurosyphilis de  Massary,  dii  Sonkh,  191 7.  . .  .20 

15.  Traumatic  general  paresis Hurst,  191 7 . ...  22 

16.  Head  trauma;  shell-shock;  mania;  W.  R.  ^ositivQ .Babonneix,  David,  1917.  . .  .23 

17.  Head  trauma  in  a  syphilitic Babonneix,  David,  191 7. . .  .24 

18.  Shell  wound:  general  paresis Boucherot,  1915 .... 25 

19.  "Shell-shock"  ocular  palsy:  sj^philitic Schtister,  1915 .... 26 

20.  Shell-shock:  general  paresis Dofiath,  1915 ....  27 

21.  Shell-shock:  tabes Logre,  1917. . .  .28 

22.  Same Dnco,  Blum,  1917.  .  .  .28 

23.  Pseudotabes  (Shell-shock) Pitres,  Marchand,  1916 ....  29 

24.  Shell-shock  neurosyphihs Hurst,  1917 . ...  30 

25.  Shell-shock  neurosj^jhihs Hurst,  1917. . .  .31 

26.  Pseudoparesis  (Shell-shock) Pitres,  Marchand,  1916. . .  .32 

27.  War  strain  and  Shell-shock  in  a  s>'philitic Karpliis,  1915 ...  .34 

28.  Shell-shock  recurrence  of  syphilitic  hemiplegia Mairet,  Pieron,  1915. . .  .36 

29.  Shell-shock  (functional!)  amaurosis  in  a  neuros3^hilitic 

Laignetr-Lavastine,  Courbon,  1916.  .  .  .37 

30.  Shell-shock  (functional)  phenomena  in  a  neurosyphilitic 

Babonneix,  David,  191 7.  .  •  .39 

31.  Vestibular  symptoms  in  a  neurosyphilitic Gtiillain,  Barre,  1916.  . .  .40 


XX  TABLE   OF   CONTENTS 

Case  Page 

32.  Syphilophobic  suicidal  attempts Colin,  Laittier,  1917 . . .  .41 

33.  Simulated  chancre Pick,  1916 . . . .  42 

34.  Exaggeration Buscaino,  Coppola,  1916 43 


n.  The  Feeble-mesDED  GROtn*  (Jlypophrenoses) 

35.  A  feeble-minded  person  fit  for  service Pruvost,  1915 

36.  An  imbecile  superbrave Pruvost,  1915 

37.  An  imbecile  fit  for  barracks  work Pruvost,  1915 

38.  A  feeble-minded  inventor Laigtiel-Lavastine,  Ballet,  191 7 

39.  A  feeble-minded  simulator Pruvost,  1915 

40.  Enlistment  for  amelioration  of  character Briand,  1915 

41.  An  imbecile  fit  for  service  at  the  front Pruvost,  1915 

42.  An  imbecile  with  sudden  initiative Lautier,  1915 

43.  Emotional  fugue  in  subnormal  subject Briand,  1915 

44.  Regimental  surgeon  versus  alienist  re  feeble-mindedness Kasian,  1916 

45.  An  imbecile  rifleman Kastan,  1916 

46.  An  imbecile  hj'pomaniacal Haiiry,  1915 

47.  Feeble-minded  desire  to  remain  at  the  front Kastan,  1916 

48.  An  imbecile  sent  back  b\'  Germans Lautier,  1915 

49.  Unfit  for  service:  feeble-mindedness? Kasian,  1916 

50.  Oniric  delirium  in  a  feeble-minded  subject Soukhanof,  1915 

51.  Shell-shock  and  burial:  situation  not  rationalized Duprat,  191 7 

52.  Shell-shock  in  weak-minded  subject;  fear,  fugues  .  .Pactet,  Bonhomme,  191 7 

III.  The  Epileptic  Group  (Epileptoses) 

53.  Epilepsy:  neurosj-phihs Hewat,  191 7 

54.  Epilepsy  brought  out  by  syphilis Bonhoefer,  1915 

55.  S>philis  in  a  psychopathic  subject Bonhoeffer,  1915 

56.  Epileptic  imbecile  court-martialed Lautier,  1916 

57.  Psychogenic   seizures  in  feeble-minded  subject Bonhoefer,  1915 

58.  Drunken  epileptic:  responsibility? Juqudier,  191 7 

59.  Epilepsy:  disciplinary  case Pellacani,  1917 

60.  Same Pellacani,  1917 

61.  Desertion :  epileptic  fugue Verger,  1916 

62.  Specialist  in  escapes Logre,  191 7 

63.  Epilepsy  and  other  factors:  disciplinary  case Consiglio,  191 7 

64.  Strange  conduct  and  amnesia  in  epileptic Hurst,  191 7 

65.  Epilepsy  after  antitNphoid  inoculation Bonhoefer,  1915 

66.  Shell-shock:  Jacksonian  seizures  —  decompression Leriche,  1915 

67.  Blow  on  head:  hysterical  convulsions  —  cure  by  neglect Clarke,  1916 

68.  Epilepsy  with  superposed  hysteria Bonhoefer,  1915 

69.  Musculocutaneous  neuritis:   Brown-Sequard's  epilepsy 

Mairet,  Pieron,  1916 

70.  Bullet  wound:  reactive  epilepsy? Bonhoefer,  1915 


44 
45 
45 
47 
49 
49 
5° 
SI 
52 
53 
55 
57 
58 
60 
61 
62 

63 
64 


65 
66 
67 
68 
69 
71 
74 
76 
78 
80 
82 
83 
84 
86 

87 
88 

89 
92 


TABLE  OF  CONTENTS 


XXI 


Case 


Page 


71.  Epilepsia  tarda Bonhoeffer,  1915 ...  .93 

72.  Convulsions  by  auto-suggestion Hurst,  1916 95 

73.  Epilepsy,  emotional Westphal,  Hiibner,  1915 ...  .97 

74.  Hysterical  convulsions Laignel-Lavastine,  Fay,  1917. . .  .98 

75.  Desertion:  fugue,  probably  not  epileptic Barat,  1914. . .  100 


76. 

77. 
78. 

79- 
80. 
81. 
82. 

83. 
84. 
8S- 

IV. 

86. 
87. 
88. 
89. 
90. 
91. 
92. 

93- 

94. 

95- 
96. 

97- 
98. 
99. 
100 

lOI, 

102 


Epileptic  episode Bonhoeffer,  1915 . . .  102 

Narcoleptic  seizures Friedmann,  1915 . . .  103 

Sham  fits Hurst,  191 7 . . .  106 

Epileptoid  attacks  controllable  by  will Russel,  191 7 . . .  106 

Epileptic  taint  brought  out  at  last  by  shell-shock Hurst,  191 7 . . .  107 

Shell-shock  epilepsia  larvata Juquelier,  Quellien,  1917. . .  108 

To  illustrate  a  theory  of  Shell-shock  as  epileptic Ballard,  1915 ...  no 

Same Ballard,  1917 . . .  no 

Same Ballard,  1917. .  .111 

Epileptic  equivalents Mott,  1916 ...  112 


The  Alcohol-Deug-Poison  Group  (Pharmacopsychoses) 

Pathological  intoxication Boucherot,  1915 

Same Loewy,  1915 

Desertion  in  alcoholism:  fugue Logre,  1916 

AlcohoHc  amnesia  experimentally  reproduced Kastan,  1915 

Desertion  and  drunkenness Kastan,  1915 

Desertion  by  alcoholic  dement Kastan,  1915 

Desertion  by  alcoholic  with  other  factors Kastan,  1915 

Alcoholism:  disciplinary  case Kastan,  1915 

Atrocity,  alcoholism Kastan,  1915 

Atrocity,  alcoholic Kastan,  1915 

Alcoholism  and  amnesia:  disciplinary  case Kastan,  1915 

Post-traumatic  intolerance  of  alcohol Kastan,  1915 

Adventure  with  Parisian  stranger Briand,  Haury,  1915 

Morphinism:  tetanus Briand,  1914 

Morphinism:  medicolegal  question Briand,  1914 

>  Two  morphinists Briand,  1914 


.113 

.  .n6 

..117 

..118 

.119 

.  121 

.  124 

,  .126 

.  127 

.128 

.  129 

.130 

.131 

.131 

.132 

.132 


V.    The  Focal  Brain  Lesion  Group  {Encephalo psychoses) 

103.  Aphasia  and  left  hemiplegia:  local  and  contrecoup  lesions .  .  L'Hermitte,  1916 .  . .  133 

104.  Gunshot  head  wound  and  alcohol:  amnesia Kastan,  1916. . .  135 

105.  Bullet  in  brain:  cortical  blindness  and  hallucinations 

Lereboullet,  Mouzon,  1917  . .  .  136 

106.  Content  of  existent  psychosis  changed  by  head  trauma 

Laignel-Lavastine,  Courbon,  191 7  .  .   139 

107.  Meningococcus  meningitis;  apparent  recovery:  dementing  psychosis 

Maixandeau,  1915.  •  •  141 


XXll  TABLE   OF   CONTENTS 

Case 

io8.   Meningococcus  meningitis Esckbach  and  Lacaze,  1915 . 

109.  Shell-shock:  meningitic  syndrome Pitres  and  Marchand,  1916. 

no.   Brain  abscess  in  a  syphilitic:  matutinal  loss  of  knee-jerks 

Dumolard,  Rebierre,  QucUien,  1915. 

111.  Spinal  cord  lesion:  early  recovery Mendelssohn,  1916. 

112.  Shell  explosion  and  meningeal  hemorrhage:  pneumococcus  meningitis 

GuiUain,  Barre,  191 7. 

113.  Ante  helium  covitxXtsiaxi:  shrapnel  wound  determines  athetosis .  5aWe»,  1916. 

114.  Hysterical  versus  thalamic  hemianesthesia Leri,  1916. 

115.  Shell-shock:  multiple  sclerosis  syndrome Pitres,  Marchand,  1916. 

116.  Mine  explosion:  hysterical  and  organic  symptoms Smyly,  191 7. 

117.  Same Smyly,  1917. 

VI.    The  Symptomatic  Group  (Somatopsychoses) 

118.  Rabies:  neuropsychiatric  phenomena 

Grenier  de  Cardenal,  Legrand,  Benoil,  1917 

119.  Tetanus,  psychotic Lumiere,  Astier,  191 7 

120.  Tetanus /n«^e  versus  hysteria Claude,  L'Hermitte,  1915 

121.  British  ofi&cer's  letter  concerning  local  tetanus Turrell,  1917 

122.  Dysentery:  psychosis Loewy,  1915 

123.  Typhoid  fever:  hysteria Sterz,  1914 

124.  Dementia  praecox  versus  posttyphoid  encephalitis Nordmann,  1916 

125.  Paratyphoid  fever:  psychosis  outlasting  fever Merklen,  1915 

126.  Paratyphoid  fever:  psychopathic  taint  brought  out Merklen,  1915 

127.  Diphtheria:  postdiphtheritic  symptoms Marchand,  1916 

128.  Diphtheria:  hysterical  paraparesis Marchand,  1915 

129.  Malaria:  amnesia De  Brun,  191 7 

130.  Malaria:  Korsakow's  sj^ndrome Carlill,  191 7 

131.  Malaria:  ventral  horn  symptoms Blin,  1916 

132.  Trench  foot;  acroparesthesia Cottet,  19 17 

133.  Bullet  injury  of  spine;  bronchopneumonia:  etat  crible  of  spinal  cord 

Roussy,  1 9 16 

134.  Shell-shock  (shell  not  seen);  sensory  and  motor  symptoms:  decubitus; 

recovery Heitz,  1915 

135.  Shell-shock;  later  typhoid  fever:  neuritis  {ante  bellum  hysteria) 

Roussy,  1915 

136.  Bullet  wound  of  pleura:  hemiplegia  and  ulnar  syndrome 

Phocas,  Gutmann,  1915 

137.  Tachypnea,  hysterical Gaillard,  1915 

138.  Soldiers'  heart Parkinson,  1916 

139.  Soldiers'  heart? Parkinson,  1916 

140.  War  strain  and  shell  wound:  diabetes  mellitus Karplus,  1915 

141.  Dercum's  disease Hollatide,  Marchand,  1917 

142.  Hyperthyroidism Tombleson,  1917 


TABLE   or    CONTENTS  XXUl 

Case  Page 

143.  Hyperthyroidism?,  neurasthenia Dejerine,  Gascuel,  1914. . .  196 

144.  Hyperthyroidism Rothacker,  1916 . . .  197 

145.  Graves'  disease,  forme  fruste Babonneix,  Celos,  1917 . . .  198 

146.  Shell-shock  hysteria:  surgical  complications Oppenheim,  1915 .  . .  199 

VII.  The  Presenile  and  Senile  Group  {Gerio psychoses)  —  No  cases. 
Vni.    The  Dementia  Praecox  Group  {Schizophrenoses) 

147.  Hatred  of  Prussia:  diagnosis,  dementia  praecox Bonhoefer,  1916 .  . .  200 

148.  Dementia  praecox:  arrest  as  spy Kastan,  1915 . . .  201 

149.  Fugue,  catatonic Boucherot,  1915 . . .  203 

150.  Desertion:  schizophrenic? Consiglio,  1916. . .  204 

151.  Schizophrenia;  alcohoUsm:  disciplinary  case Kastan,  1915. . .  206 

152.  Schizophrenia  aggravated  by  service dela  Motte,  1915 . . .  208 

153.  Shot  himself  in  hand:  delusions Rouge,  1915 . . .  209 

154.  Dementia  praecox  volunteer Haury,  1915 . . .  210 

155.  Hysteria  versus  catatonia Bonhoefer,  1916. . .  211 

156.  "Hysteria"  actually  dementia  praecox Hoven,  1915. . .  213 

157.  Hallucinatory  and  delusional  contents  influenced  by  war  experiences 

Gerver,  1915.  ..214 

158.  Iron  cross  winner,  hebephrenic Bonhoeffer,  1915 . . .  215 

159.  Occipital  traiuna;  visual  hallucinations Claude,  UHermiite,  1915 .  . .  217 

160.  Shell-shock:  Dementia  praecox Weygandt,  1915 . . .  219 

161.  Same Dupuoy,  1915 . . .  220 

162.  Shell-shock;  fatigue;  fugue;  delusions Rouge,  1915 . . .  221 

IX.  The  Manic-Depbessive  Group  (Cyclothymoses) 

163.  A  maniacal  volunteer Boucherot,  1915 . . .  222 

164.  Fugue,  melanchoUc Logre,  1917.  .  .223 

165.  Apples  in  No-man's-land Weygandt,  1914 . . .  224 

166.  Trench  life:  depression;  hallucinations;  arteriosclerosis;  age,  38 

Gerver,  1915. .  .225 

167.  War  stress:  manic  depressive  psychosis Dumesnil,  1915 . . .  226 

168.  Predisposition;  war  stress:  melanchoha Dumesnil,  1915. . .  227 

169.  Depression;  low  blood  pressure;  pituitrin Green,  1916 . . .  228 

X.  The  Psychoneurotic  Group  {Psychoneuroses) 

170.  Three  phases  in  a  psychopath Laignel-Lavastine,  Courbon,  1917 . . .  229 

171.  Fugue,  probably  hysterical Milian,  1915 . . .  232 

172.  Hysterical  Adventist dela  Motte,  1915 . . . 234 

173.  Fugue,  psychoneurotic Logre,  . . .  235 

174.  Shell-shy;    war  bride  pregnant:    fugue  with  amnesia  and  mutism 

Myers,  1916. . .  236 

175.  A  neurasthenic  volunteer E.  Smith,  1916 . . .  237 


Xxiv  TABLE   OF   CONTENTS 

Case  Page 

176.  War  stress:  neurasthenia  in  subject  without  heredity  or  soil.  .Jolly,  1916.  .  .238 

177.  Arterial  hypotension  in  psychasthenia Crouzon,  1915 . . .  239 

178.  War  stress:  psychasthenia Eder,  1916 .  . .  240 

179.  Ante  helium  attacks:  neurasthenia Binswanger,  1915.  . .  241 

180.  Antityphoid  inoculation:  neurasthenia Consiglio,  191 7 .  . .  244 

181.  Neurasthenia  (one  symptom:  sympathy  with  the  enemy) . .  .Steiner,  1915 .. .  245 

XI.  The  Psychopathic  Group  {Psycho pathoses) 

182.  Claustrophobia:  shells  preferred  to  tunnel Steiner,  1915 .  . .  246 

183.  Pathological  Uar Henderson,  1917 ...  247 

184.  Psychopath  almost  Bolshevik Hoven,  1917. . .  249 

185.  Hysterical  mutism:  persistent  delusional  psychosis Dumcsnll,  1915 . . .  250 

186.  Psychopathic  inferiority  brought  out  by  the  war  .  .  . Bennati,  1916.  . .  251 

187.  Psychopathic  episodes Pellacani,  1917.  . .  252 

188.  Maniacal  and  hysterical  delinquent .Buscaino,  Coppola,  1916. . .  253 

189.  Psychopathic  delinquent Buscahio,  Coppola,  1916. . .  254 

190.  Psychopathic  excitement Buscaino,  Coppola,  1916 . . .  255 

191.  Desertion:  dromomania Consiglio,  1917 .  . .  256 

192.  Suppressed  homosexuality R.  P.  Smith,  1916 ...  257 

193.  Psychopathic:  at  first  suicidal,  then  self-mutilative MacCiirdy,  1917.  . .  258 

194.  Bombardment:  psychasthenia Laignel-Lavastine,  Courbon,  1917.  .  .259 

195.  Nosophobia Colin,  Lautier,  191 7 .  . .  261 

196.  Psychopath:  Attacks  of  disgust  and  terror Lattes,  Goria,  1915. . .  262 

SECTION  B.    SHELL-SHOCK:  NATURE  AND  CAUSES 

197.  Shell  explosion:   Autopsy  —  hemorrhages;   vagoaccessorius  chroma- 

tolysis Mott,  1917.  .  .265 

198.  Mine  explosion:  Autopsy  —  hemorrhages Chavigny,  1916 ...  270 

199.  Mme  explosion:    Autopsy  —  hemorrhages Roussy,  Boisseau,  1916 ...  271 

200.  Shell  fragment  in  back:  Autopsy  —  softenings  in  spinal  cord 

Claude,  L'Hermitte,   1915 . . .  272 

201.  Shell  explosion:  Autopsy  —  lungs  burst! Sencert,  1915 ...  274 

202.  Shell  explosion:  Hemorrhage  in  spinal  canal  and  bladder Ravaut,  1915. . .  276 

203.  Shell  explosion:  Hemorrhage  and  pleocytosis  of  spinal  fluid 

Froment,  1915.  .  .277 

204.  Shell  explosion:  Pleocytosis  of  spinal  fluid Guillain,  1 915 ...  279 

205.  Shell  explosion:   Pleocytosis  of  spinal  fluid  as  late  as  a  month  after 

explosion Souques,  Donnet,  1915 .. .  280 

206.  Burial:  Thecal  hemorrhage Leriche,  1915 . . .  282 

207.  Shell  explosion:  Hypertensive  spinal  fluid Leriche,  1915 . . .  283 

208.  Bullet  wound:  HematomyeUa;  partial  recovery Mendelssohn,  1916. . .  284 

209.  Shell  explosion,  subject  prone:  HematomyeUa Babinski,  1915 .  . .  286 

210.  Struck   by   missile:    Hysterical   paraplegia?     Herpes;    segmentary 

symptoms Elliot   1914 .  . .  288 


TABLE  OF  CONTENTS  XXV 

Case  '  Page 

211.  Mine  explosion:  Head  bruises,  labjninth  lesions,  canities  unilateral 

Lebar,  1915. . .291 

212.  Shrapnel  wounds:  Focal  canities;   hysterical  symptoms. .  . Arinstein,  1915. .  .292 

213.  Burial:  Organic  (?)  hemiplegia Marie,  Levy,  1917.  .  .293 

214.  Shell    explosion;    no    wound:    Organic   and   functional   symptoms 

Clatide,  L'HertniUe,  1915 . . .  294 

215.  Gassing:  Organic  S3anptoms Neiding,  1917 . . .  296 

216.  Gassing:  Mutism,  battle  dreams Wiltshire,  1916.  . .  297 

217.  Shell  explosion:  Organic  deafness;  hysterical  speech  disorder 

Binswanger,  1915 .  . .  298 

218.  Distant  shell  explosion  not  seen  or  heard:  Tympanic  rupture,  cere- 

bellar symptoms Pitres,  Marchand,  1916 .  . .  300 

219.  Mine  explosion:  Organic  and  functional  symptoms Smyly,  191 7.  .  .302 

220.  Shrapnel  skull  wound:   Differential  recovery  from  functional  symp- 

toms   Binswanger,  191 7 .  . .  303 

221.  Shell  explosion  shrapnel  wound:  Battle  memories,  scar  hyperesthetic 

Bennati,  1916. .  .305 

222.  Shrapnel  wounds,  operation:  Hysterical  facial  spasm Batten,  191 7. .  .306 

223.  Shell  explosion:  Tremors  and  emotional  crises Myers,  1916.  .  .307 

224.  Shell  explosion,  comrades  killed:  Tremors,  crises Meige,  1916.  .  .308 

225.  Under  fire:  Tremophobia:  French  artist's  description Meige,  1916.  .  .310 

226.  Shell  explosion:    German  soldier's  account  of  Shell-shock  symptoms 

Gaupp,  1915...  312 

227.  A  British  soldier's  account  of  shell-shock Batten,  1916 . . .  315 

228.  Blown  up  by  shell:  Crural  monoplegia;  hysterical  four  days  later  Leri,  1915 . .  .317 

229.  Shell  explosion  nearby:    Description  of  treatment  to  demonstrate 

hysterical  nature  of  characteristic  symptoms Binswanger,  1915  . .  .318 

230.  Leg  wound:  Pseudocoxalgic  monoplegia  and  anesthesia 

Roussy,  L'Hermitte,  191 7. .  .323 

231.  Leg  contusion:    Crural  monoplegia,  hysterical;  later  crutch  paraly- 

sis, organic Babinski,  1917 . . .  324 

232.  War  strain:  Arthritis;  crural  monople^a  and  anesthesia;  hysterical 

"conversion  hysteria" MacCurdy,  1917 .  . . 325 

233.  Lance  thrust  in  back;  Crural  monoplegia Binswanger,  1915 .  . .  326 

234.  Shell  explosion:    After  six    days,  crural    monoplegia   ("metatrau- 

matic"  suggesting  persisting  hypersensitive  phase  after  shell-shock) 

Schuster,  1916.  .  .329 

235.  Wound  of  foot:   Acrocontracture,  seven  months'  duration;  psycho- 

electric  cure  at  one  sitting Roussy,  L'Hermitte,  191 7 . . .  330 

236.  Shell  explosion:  Trauma;  emotion;  hysterical  paraplegia. ^46ro/ta?»5,  1915. .  .332 

237.  Shell  explosion:  Burial;  paraplegia Elliot,  1914.  .  .334 

238.  Shell  explosion:  Paraplegia  and  sensory  symptoms,  organic? .  .Hurst,  1915 . . .  335 

239.  War  strain  and  rhevunatism;  no  emotional  factors:  Paraplegia,  later 

brachial  tremor Binswanger,  191 5  .  . .  336 


XXVI 


TABLE   OF   CONTENTS 


Case 

240.  Emotion  in  fever  patient  from  watching  barrage  creep  up:  Para- 

plegia   Mann, 

241.  Incentives,  domestic  and  medical,  to  paraplegia Russel, 

242.  Bullet  in  back:  Hysterical  bent  back;  " camptocormia " .  .  .Souques, 

243.  Shell  explosion:  Camptocormia  . Roussy,  UHermitte, 

244.  Shell  explosion;  burial:  camptocormia Roussy,  L'Hermitte, 

245.  Shell  explosion;  burial;  Paraplegia,  later  camptocormia. . .  .Joltrain, 

246.  Bullet  in  thigh:  Astasia-abasia.    Wound  of  neck:  Again  astasia-abasia 

Roussy,  UHermitte, 

247.  Shell  explosion:  Wound  of  thorax;  astasia-abasia 

Roussy,  VHermiite, 

248.  War  strain  and  fall  in  trench  without  trauma:  Dysbasia. .  ..Nonne, 

249.  Shell  explosion:  Partial  burial;  hysterical  sjonptoms  in  parts  buried 

Arinstein, 

250.  Wound  of  hand:  Acroparalysis Roussy,  UHermitte, 

251.  Wound  of  arm:  Hysterical  paralysis Chartier 

252.  Wound  in  brachial  plexus  region :  Supinator  longus  contracture 

Leri,  Roger, 

253.  Contusion  of  muscle  with  " stupef active "  paralysis  of  biceps  (supi- 

nator longus  still  functioning) Tinel, 

254.  Wound  of  arm:  Blockage  of  impulses  to  hand  movements.  . .  Tubby, 

255.  Shell  explosion:   Bilateral    symmetrical  phenomena Gerver, 

256.  Shell  explosion:    Paralytic  symptoms  on  side    exposed:    Contra- 

lateral irritative  symptoms Oppenheim, 

257.  Shell  explosion:  Bilateral  asymmetrical  symptoms Gerver, 

258.  Shell  explosion:  Sensory  disorder  on  side  exposed Gerver, 

259.  Shell  explosion:  Hysterical  deafness  and  other  s>Tnptoms;  relapse 

Gaupp, 

260.  Shell  explosion:  Deafness Marriage, 

261.  Mine   explosion:    Deafmutism;    recovery    on   epistaxis   and   fever 

Liebault, 

262.  Shell  explosion:  Deafmutism Motl, 

263.  Shell  explosion:  Deafmutism  and  convulsions Myers, 

264.  Gunfire:  Aphonia Bldssig, 

265.  Shell-shock  mutism:    (a),  observed,  {b)  dreamed  of,   (c),  developed 

by  victim  of  shell  explosion Mann, 

266.  Mortar  explosion:  Deafness Lattes,  Goria, 

267.  Shell-explosion:  onomatopoeic  noises Ballet, 

268.  Shell  explosion:  Gravel  in  eyes;  eye  and  face  symptoms.  .Ginestous, 

269.  Shell  explosion;  burial;  blow  on  occiput;  Blindness Greenlees, 

270.  Shell-shock  amblyopia:  Composite  data Parsons, 

271.  Factors  in  shell-shock  amblyopia:  Excitement,  blinding  flashes,  fear, 

disgust,  fatigue Pemberton, 

272.  Shell  explosion  amblyopia Myers, 


Page 


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917. 
917. 

917. 

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916. 
917. 
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915- 

917. 
915- 
915- 

915- 
915- 
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916. 
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917. 
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915- 


TABLE   OF  CONTENTS  XXVll 

Case  Page 

273.  Shell  windage  without  explosion:  Cranial  nerve  disorder  .Pachanioni,  1917 . . .  378 

274.  Initial  case  in  Babinski's  series  to  show  chloroform  elective  exagger- 

ation of  reflexes Babinski,  Froment,  1917.  .  .380 

275.  Wound  of  ankle:  Contracture,  chloroform  effect 

Babinski,  Froment,  191 7. .  .383 

276.  "Reflex"  disorder  of  right  leg:  Chloroform  effect 

Babinski,  Froment,  191 7.  .  .384 

277.  Bullet  in  calf:    Hysterical  lameness  cured  —  reflex  disorder  asso- 

ciated therewith  not  cured Vincent,  1916 .  . .  385 

278.  Trauma  of  foot:    Hysterical  dysbasia  and  reflex  disorders;    differ- 

ential disappearance  of  hysterical  symptoms Vincent,  191 7.  .  .386 

279.  Shell-shock    and    paraplegia:    Vasomotor    and    secretory    disorder 

twenty  months  later Roussy,  1917. .  .387 

280.  Tetanus    clinically    cured:     Phenomena  reproduced  under  chloro- 

form anesthesia Monier-Vinard,  191 7 .  . .  388 

281.  Example  of  a  "reflex"  disorder  after  shell  explosion  at  great  distance 

Ferrand,  1917.  .  .390 

282.  Shell  fire:  Shell-shock  symptoms  delayed McWalter,  1916.  .  .391 

283.  Shell-shock  symptoms  early  and  late Smyly,  191 7 .  . .  392 

284.  Wounds:  Gassing;  burial;  collapse  on  home  leave Elliot  Smith,  1916.  .  .393 

285.  Late  sjTnpathetic  nerve  effect  after  buUet  wound  of  neck.  .  .  . Tubby,  1915 .  .  .394 

286.  Hysterical  crural  monoplegia  after  fall  from  horse  under  fire  (reminis- 

cence of  similar  ante  helium  accident) Forsyth,  1915 .  . .  395 

287.  Shell  explosion,  cave-in:  Right  leg  symptoms  {ante  bellum  experiences) 

Myers,  1916.  .  .396 

288.  Shell  explosion,  wound  of  back:  Paraparesis  (subject  always  weak  in 

legs) Dejerine,  1915  .  . .  397 

289.  Wound  near  heart:  Fear;   paraparesis  (subject  always  weak  in  legs) 

Dejerine,  1915.  .  .399 

290.  Wounds:   Tic  on  walking  and  recovery  except  frontalis  tic  (empha- 

sis of  a?ite  bellum  habit) Westphal,  Htibner,  1915 .  . .  401 

291.  Fatigue  and  emotion:  Hysterical  hemiplegia  (similar  hemiplegia  awfe 

bellum) Roussy,  VHermitte,  1917 . . .  402 

292.  War  strain:   Hemiplegia  (similar  hemiplegia  ante  bellum,  subject's 

father  hemiplegic) Dupres,  Rist,  1914 .  . .  403 

293.  Shell  explosion   and   burial:    Deaf  mutism    (speech   difl&culty   ante 

bellum)  '. MacCurdy,  1917 . . .  405 

294.  War  strain:    Shell-shock  and  psychotic  sjonptoms   determined   to 

parts  ante  bellum Zanger,  1915 .  . .  406 

295.  Mine  explosion:  Emotion;  delirium  (previous  head  trauma  without 

unconsciousness) Lattes,  Goria,  1917. .  .407 

296.  Sniper  stricken  blind  in  shooting  eye Eder,  1916. .  .408 

297.  Anticipation  of  warfare:    Fall  while  mounting  sentry;  hysterical 

blindness Forsyth,  1915 .  . .  408 


XXVm  TABLE    OF    CONTENTS 

Case  Page 

298.  Spasmodic    neurosis    from   bareback    riding    (similar    episode   aitle 

bdlum)  Schuster,  1914.  .  .409 

299.  Ante  beUiim  spasm  of  hands Hewat,  191 7 .  . .  409 

300.  Quarrel:   Hysterical  chorea,  reminiscent  of  former  attack  and  itself 

reminiscent  of  organic  chorea  in  subject's  mother Diipiwy,  1915 .  . .  411 

301.  Hallucinations  and  delusions  of  ante  bdlum  origin:   Treatment  by 

explanation Rows,  1916.  .  .412 

302.  Tremors  and  convulsive  crises  in  a  poor  risk Rogues  de  Fursac,  1915  .  .  .413 

303.  Emotionality  and  tachycardia  in  a  martial  misfit Bemiaii,  1916 .  . .  415 

304.  Hereditary  instabihty Wolfsohn,  1918 .  . .  416 

305.  Genealogical  tree  of  a  shoemaker Wolfsohn,  1918 .  . .  417 

306.  Traumatic   hysteria   without  hereditary   or  acquired  psychopathic 

tendency Donalh,  1915 .  .  .418 

307.  Mine  explosion,  burial:  Neurosis  in  perfectly  normal  soldier 

MacCurdy,  1917.  .  .419 

308.  Shell  explosion:  Tremophobia Meige,  1916. .  .421 

309.  Frozen  in  bog:  Glossolabial  hemispasm Binsn'anger,  1915  .  . .  424 

3 10.  Bruise  by  horse :    In\-incible   pain  —  subject  cured  by  performing 

heroic  feat Loe-d'y,  1915 .  . .  426 

311.  Kick  by  horse:  Hysterical  symptoms  including  monocular  diplopia 

Oppenheim,  191 5.  .  .427 

312.  Windage  from  non-exploding  shell :  Emotion;  homonymous  hemian- 

opsia   Steiner,  1915  .  . .  428 

313.  Shell-shock  psoriasis GaucJier,  Klein,  1916.  .  .429 

314.  Croix  de  guerre  and  Shell-shock  got  simultaneously:   Hallucinatory 

bell-ringing  reminiscent  of  civilian  work 

Laignel-Lavastine,  Courbon,  1916...430 

315.  Waked    by  shell  explosion:    Nystagmiform  tremor   (occupational 

reminiscence  in  cinema  worker)  and  tachycardia Tinel,  1915 .  .  .432 

316.  Synesthesialgia:  Foot  pain  on  rubbing  dry  hands 

Lortat-Jacob,  Sezary,  1915.  .  .433 

317.  Shell-shock  and  burial:   Clonic  spasms,  later  stupor Gaupp,  1915.  .  .435 

318.  W^ar  stress  (liquid  fire)  and  sheU-shock:   PueriUsm 

Charon,  Halberstadt,  1916.  .  .437 

319.  Bombed  from  aeroplane:  Battle  dreams;  dizziness;  fugue 

Lattes,  Goria,  1917.  .  .439 

320.  Hyperthyroidism  after  box  drops  from  aeroplane Bennati,  1916.  .  .440 

321.  Shell  dropped  without  bursting:  Stupor  and  delirium.  .Lattes,  Goria,  191 7.  .  .441 

322.  Subject  carrying  explosives  is  jostled:   Unconsciousness,  deaf  mutism, 

later  camptocormia Lattes,  Goria,  191 7 .  . .  443 

323.  Grazed  by  sUding  caimon:  Stupor  and  amnesia Lattes,  Goria,  1917.  .  .444 

324.  Shell  explosions  nearby:  Emotion  and  insomnia Wiltshire,  1916.  .  .445 

325.  Shell  explosion:  symptoms  after  hearing  artillery  twelve  days  later 

Wiltshire,  1916. .  .446 


TABLE    OF    CONTENTS  XXIX 

Case  Page 

326.  Exhaustion  (heat?):  Hyperthyroidism,  hemiplegia Oppenheim,  1915. .  .447 

327.  War  strain  and  rheumatism:  tremors Binswanger,  1915 . .  .448 

328.  Shell  explosion;  emotion:  Fear  and  dreams Mott,  1916. .  .451 

329.  Under  fire;    barbed  wire  work:  tremors  and  sensory  symptoms 

Myers,  1916. .  .452 

330.  Shell  explosion:   Emotional  crises;   twice  recurrent  mutism 

Mairet,  Pier  on,  Bouzansky,  1915. .  .453 

331.  Shell  explosion:  Emotional  crises  (fright  at  a  frog) 

Claude,  Dide,  Lejonne,  1916. .  .455 

332.  War  strain;   wound;   burials;  sheU-shock:  neurosis  with  anxiety  and 

dreams:  Relapse MacCurdy,  1917 .  .  .457 

S:^^.   Bombed  by  airplane:   Suicidal  thoughts;   oniric  delirium;   "moving 

picture  in  the  head" Hoven,  1917 .  .  .460 

334.  Shell  explosion;  emotion  at  death  of  best  friend:  Stupor  and  amnesia 

Gaupp,  1915. . .462 

335.  Emotional  shock  from  shooting  comrade:   Horror,  sweat,  stammer, 

nightmare Rows,  1916 .  . .  463 

336.  Emotion  at  death  of  comrade:  Phobias Bennati,  1916. .  .464 

337.  Shell  explosion:  Fright;  delayed  loss  of  consciousness Wiltshire,  1916. .  .465 

338.  Shell  explosion;    burial  work:    amnesia;    unpleasant  ideas  reflexly 

conditioned  by  shell  whisthng Wiltshire,  1916.  .  .467 

339.  Comrade's  death  witnessed:  Suicidal  depression Steiner,  1915.  .  .468 

340.  Marching  and  battles:  Neurasthenia? Botthoeffer,  1915 .  .  .469 

341.  English  schoolmaster's  account  of  dreams Mott,  1918. .  .470 

342.  War  dreams  shifting  to  sex  dreams Rows,  1916.  .  .472 

343.  Shock  at  death  of  comrade:  War  and  peace  dreams Rows,  1916. .  .474 

344.  War  dreams  including  hunger  and  thirst Mott,  1918.  .  .475 

345.  Burial  work:  Olfactory  dreams  and  vomiting Wiltshire,  1916.  .  .476 

346.  War  dreams:  Phobia  conditioned  on  postoniric  suggestion .  .Duprat,  1917. .  .477 

347.  Service  in  rear:  War  dreams  not  based  on  actual  experiences 

Gerver,  1915.  .  .478 

348.  Hysterical  astasia-abasia:  Heterosuggestive  "big  belly" 

Rotissy,  Boisseau,  Cornil,  191 7. .  .479 

349.  Collapse  going  over  the  top:  Neurasthenia.  . Jolly,  1916. .  .481 

350.  Battles:  Mania  and  confusion Gerver,  1915 .  .  .483 

351.  Machine-gun  battle:  Mania  and  hallucinations Gerver,  1915. .  .484 

352.  Attacks  and  counter-attacks:  Incoherence  and  quick  development  of 

scenic  war  hallucinations Gerver,  1915 .  . .  485 

353.  Hysterical  stupor  under  shell  fire  after  2  days  in  the  trenches 

Gaupp,  1915. .  .486 

354.  Monosymptomatic  amnesia Mallet,  191 7 . .  .488 

355.  Aviator  shot  down:  Mental  symptoms,  organic MacCurdy,  1917. .  .489 

356.  Shell  fire  and  corpse  work:  Daze  with  relapse;  mutism Mann,  1915 . .  .491 

357.  Mine  explosion:  Confusion Wiltshire,  1916.  .  .492 


XXX  TABLE    OF    CONTENTS 

Case 

358.  Shell  explosion:  Alternation  of  personality Gaupp,  1915 

359.  "A  Horse  in  the  Unconscious" Eder,  1916 

360.  Shell  explosion,  gassing,  fatigue:  Anesthesia Myers,  1916 

361.  Shell  explosion  and  burial:   Somnambulism;   dissolution  of  amnesia 

under  hypnosis Myers,  1915 

362.  Shell  explosion  with  injuries:  Somnambulism Donath,  1915 

363.  Shock:  Stupor  as  if  dead Regis,  1915 

364.  Emotions  over  battle  scenes:  Twenty-four  days'  somnambuHsm 

Milian,  1915 

365.  Putative  loss  of  brother  in  battle:    Somnambulism   and  mutism 

twenty-seven  days Milian,  1915 

366.  Shell  explosion:  Trauma,  windage:  Somnambulism  four  days 

Milian,  1915 

367.  Burial,  head  trauma;  gassing:  Tremors,  convulsions,  confusion,  fugue 

Consiglio,  1916 

368.  Shell  explosion:  Hysterical  symptoms  and  tendency  to  fugue 

Binswanger,  1915 

369.  Burial:  Dissociation  of  personality Felling,  1915 

370.  Ear  CompUcations  and  hysteria Buscaino,  Coppola,  1916 

SECTION  C.     SHELL-SHOCK  DIAGNOSIS 

371.  Value  of  lumbar  puncture Souqties,  Donnet,  1915 

372.  Meningeal  and  intraspinal  hemorrhage:  Lumbar  pimcture .  .Guillain,  1915 

373.  Burial:   Slight  hj-peralbuminosis Ravaut,  1915 

374.  Paraplegia,  organic:  Lumbar  puncture Joiiberl,  1915 

375.  Gunshot  of  spine :  Spinal  concussion,  quadriplegia,  cerebellospasmodic 

disorder Claitde,  L'Hermitte,  191 7 

376.  Trauma  of  spine:    Anesthesia  and  contracture,  homolateral,  with 

trauma , . . .  .  Oppenheim,  1915 

377.  Mine  explosion  combining  hysterical  and  lesional  effects. .  .Dupouy,  1915 

378.  Shell  explosion:  Hysterical  and  organic  symptoms Hurst,  1917 

379.  Gunshot:     Cauda    equina   symptoms,    combined    with    functional 

paraplegia Oppenheim,  1915 

380.  Intraspinal  lesion :  Persistent  anesthesia Buzzard,  1916 

381.  Functional  shell-shock:  Erroneous  diagnosis Buzzard,  1916 

382.  Retention  of  urine  after  shell-shock Guillain,  Barre,  1917 

383.  Same Guillain,  Barre,  1917 

384.  Incontinence  of  urine  after  shell-shock  and  burial 

Guillain,  Barre,  191 7 

385.  Struck  by  missile :  Crural  monoplegia;  plantar  reflex  absent 

Paulian,  1915 

386.  Shell  explosion:  Crural  monoplegia;  sciatica  (neuritis?) . . .  .Souques,  1915 

387.  Functional  paraplegia  and  internal  popliteal  neuritis Roussy,  1915 

388.  Bullet  in  hip:  Local  "stupor"  of  leg Sebileau,  1914 


TABLE    OF    CONTENTS  XXXI 

Case  Page 

389.  Localized  catalepsy:  Hysterotraumatic Sollier,  191 7 . . .  544 

390.  Contracture:  Hysterotramnatic Sollier,  1917 . . .  545 

391.  Crural  monoplegia,  tetanic:  Recovery Routier,  1915 . . .  546 

392.  Spasms,  contracture,  crises  —  tetanic Meriel,  1916. .  .548 

393.  Shell  explosion,  windage,  flaccid  paraplegia,  not  "spinal  contusion" 

Leri,  1915...SS0 

394.  Scalp  wound:  Quadriparesis;  paraplegia,  cataleptic  rigidity  of  anes- 

thetic legs Clarke,  1916 ...  551 

395.  Shell  explosion:    Spasmodic  contractions  of  sartorii,  persistent  in 

sleep Myers,  1916 . . .  553 

396.  Shell  explosion:  Brown-Sequard's  S3mdrome,  hematomyelic?  . .  Ballet,  1915 . . .  555 

397.  Question  of  structural  injury  of  spinal  cord Smyly,  191 7 . . .  557 

398.  Dysbasia,  psychogenic  round  an  organic  nucleus  (cerebellar?) 

Cassirer,  19 1 6. .  .557 

399.  Shell  explosion :  Dysbasia,  in  part  hysterical,  in  part  organic? 

Hiirst,  1915...S58 

400.  Peculiar  walking  tic Chavigny,  191 7 . . .  559 

401.  Mine  explosion:  Camptocormia.   Hospital  rounder  twenty  months — 

cure  by  electrotherapy,  i  hour 

Marie,  Meige,  Behagne,  Souques,  Megevand,  1917. .  .561 

402.  Astasia-abasia Guillain,  Barre,  1916 .  . .  563 

403.  Shell  wounds:  Abdominothoracic  contracture,  tetanic,  four  months 

after  injury Marie,  1916 . . .  564 

404.  Shoulder  dislocation:  Hysterical  paralysis  of  arm Walther,  1914. .  .566 

405.  Gimshot:  Paralysis  of  arm  increasing  in  degree Oppenheim,  1915. .  .567 

406.  Wound  of  wrist:    Differential  glove  anesthesias Romner,  191 5 . . .  568 

407.  Hysterical  contracture  combined  with  edema  and  vasomotor  dis- 

order   Ballet,  1915 . . .  569 

408.  Hemiparesis  with  syringomyelic  dissociation  of  sensations:  Hem- 

atomyelia? Ravaut,  1915 . . .  570 

409.  Brachial  monoplegia:  Tetanic Routier,  1915 . . .  571 

410.  Paralysis  of  right  leg:  Hysterical?     Organic?     "Microorganic"? 

Von  Sarbo,  191 5 ...  572 

411.  Shell  explosion:  Burial:  Paralysis  on  third  day 

Leri,  Froment,  Mahar,  1915.  .  .573 

412.  Shell  explosion:  Hemiplegia.     Plantar  areflexia Dejerine,  1915.  .  .575 

413.  Shell  explosion:  Tic  versus  spasm Meige,  1916 .  . .  577 

414.  Shell  explosion:  Tremors,  anaesthesias Mott,  1916 .  . .  580 

415.  Hysteria,  appendix  to  trauma MacCurdy,  191 7 . . .  582 

416.  Peripheral  nerve  injury:  Neurasthenic  hyperalgesia Weygandt,  1915 . . .  583 

417.  Soldier  lead  worker:  Peripheral  neuritis Shufflebotham,  1915 . . .  584 

418.  "Peripheral  neuritis"  cured  by  faradism Car  gill,  1916 . . .  585 

419.  Late  tetanus Bouquet,  1916 . . .  586 

420.  Spasmodic  neurosis  and  neurasthenia Oppenheim,  1915 . . .  588 


xxxu 


TABLE    OF    CONTENTS 


Case 

421. 

422. 


Hysterical  and  reflex  ("  physiopathic  ")  disorders Babinski,  1916 

Bullet  wound:    Paralysis  non-" organic,"  non-hysterical,  i.e.  reflex 

Babinski,  Froment, 

Asymmetry  of  reflexes  under  chloroform Babinski,  Frotnent, 

Reflexes  imder  chloroform Babinski,  Froment, 

Same Babinski,  Froment, 


423- 
424. 

425- 

426.   Shrapnel  wound: 


427. 
428. 
429. 
430- 
431- 
432. 
433- 
434- 
435- 
436. 
437- 
438- 
439- 
440. 
441. 
442. 

443- 
444. 

445- 
446. 

447- 
448. 
449. 

450- 
451- 
452. 
453- 
454- 
455- 
456. 
457- 
458- 
459- 
460. 
461. 
462. 


Monoplegia,  hysterical  and  organic 

Babinski,  Froment, 

Gunshot,  later  Erb's  palsy:  "reflex"? Oppenheim, 

Paralysis  hysterical?    Organic? Gougerot,  Charpentier, 

Same Gougerot,  Charpentier, 

Same Gougerot,  Charpentier, 

rReflex  "paralysis" Delherm, 

Shell  explosion:  Functional  blindness,  monosymptomatic . .  .Crouzon, 

Retrobulbar  neuritis  (nitrophenol) Sollier,  Jousset, 

Eye  symptoms,  hysterical Westphal, 

Sandbag  on  head:  Eye  sjTnptoms:  Lenses Haru'ood, 

Hemianopsia,  organic  or  functional? Steiner, 

Hysterical  pseudoptosis LMrignel-Lavastine,  Ballet, 

SheU  explosion :  Rombergism Beck, 

Case  for  otologists  atui  neurologists Roussy,  Boisseau, 

Jacksonian  syndrome:  Hysterical Jeanselme,  Huet, 

Leg  tic :  Phobia  against  crabs Duprat, 

Convulsions  reminiscent  of  fright Duprat, 

Fatigue,  delusions,  fugue  Mallet, 

Obsessions  and  fugue Mallet, 

Aprosexia  and  birdhke  movements Chavigny, 

Shell  explosion:  Unconsciousness  (45  days):  Mutism Liebault, 

Shell  explosion :  Recurrent  amnesia Mairet,  Pier  on. 

Shell  explosion :  Comrade  killed :   Amnesia Gaupp, 

Shell  explosion :  Recurrent  amnesia Mairet,  Pieron, 

Soldiers'  heart,  neurotic  and  organic MacCurdy, 

Soldiers'  heart,  neurotic MacCurdy, 

Shell  explosion:  Hysteria:  Mahngering  (?) Myers, 

Officer  who  could  not  kick Mills, 

"Simulation":  Diagnosis  incorrect Voss, 

Wound :  Hysterical  edema? Lebar, 

Head  trauma :  simulation?     Hysteria?     Surgical? Voss, 

Disease  and  disorder  to  avoid  service Collie, 

Yes-No  test  in  anesthesia Mills, 

Guardhouse  test Roussy, 

Light  in  a  dark  room Briand,  Kalt, 

Mutism  simulated Sicard. 


Page 

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..646 

I9I6. 

..648 

I9I6. 

•  ■649 

I9I7. 

•  •651 

1915- 

•  •651 

I9I7. 

..652 

I9IS 

•  654 

TABLE    OF    CONTENTS  XXXlll 

Case  Page 

463.  Deafmutism  simulated Myers,  1916 . . .  655 

464.  Same:  Explained  by  patient Myers,  1916 ...  657 

465.  Deafmutism:  Appearance  of  malingering Gradenigo,  1917 . . .  658 

466.  A  lame  rascal Gilles,  1917 . . .  659 

467.  Picric  acid  jaundice Briand,  Hatiry,  1916 . . .  660 

468.  Swelling  of  hand  and  arm,  7  months Leri,  Roger,  1915 ...  663 

469.  Shell-shy  German Gaiipp,  1915 ...  664 

470.  Germany  sends  back  a  simulator Marie,  1915 . . .  664 

471.  Simulation  of  Quincke's  disease Leivitus,  1915 . . .  665 

472.  "Pensionitis" Collie,  1915.  .  .666 


SECTION  D.     SHELL-SHOCK  TREATMENT  AND  RESULTS 

473.  Deafmutism:  Spontaneous  cure Mott,  1916.  . 

474.  Two  returns  to  the  front Gilles,  1916 . . 

475.  Vicissitudes  in  15  months Purser,  1917 . . 

476.  Deafmutism:  Spontaneous  cure Jones,  1915 .  . 

477.  Course  of  an  oniric  delirixun Biiscaiiw,  Coppola,  1916 .  . 

478.  Same Buscaino,  Coppola,  1916 .  . 

479.  Paraplegia:  Cure  by  Iron  Cross Nonne,  1915 .  . 

480.  Mutism  cured  by  getting  drunk Proctor,  1915 .  . 

481.  Mutism  cured  by  working  in  vineyard Anon,  1916 .  . 

482.  Deafmutism:   Spontaneous  recovery  of  speech.     Recovery  of  hear- 

ing by  isolation Zanger,  1915 . 

483.  Excess  of  sympathy  on  furlough Binswanger,  19 15  - 

484.  Hysterical  seizures  treated  by  hydrotherapy Hirschfeld,  1915 .  , 

485.  Low  blood  pressure  treated  by  pituitrin Green,  191 7 .  . 

486.  Manual  contracture:   Various  treatments Duvernay,  1915 .  . 

487.  Massage  and  mechanotherapy Sollier,  1916 .  . 

488.  Mine  explosion;  headache:  Lumbar  puncture Ravatit,  1915 .  . 

489.  Hysterical  clenched  fist:  Treatment  by  fatigue  of  flexors Reeve,  1917 . . 

490.  Hysterical  adduction  of  arm:  Treatment  by  induced  fatigue.  .Reeve,  191 7. 

491.  Hysterical  cross-legs:  Treatment  by  induced  fatigue Reeve,  191 7 . 

492.  Hysterical  torticoUis:  Treatment  by  induced  fatigue Reeve,  1917 . 

493.  Claw  foot  (2  years):  Cure  by  induced  fatigue Reeve,  1917. 

494.  Tratimatic  and  post-traumatic  effects:  Surgical  treatment 

Binswanger,  191 7. 

495.  Vomiting:  Cure  by  restoration  of  self-confidence McDowell,  1917 . 

496.  Self-accusatory  delusions:  Treatment  by  "autognosis" Brown,  1916. 

497-1 

498.  [  Deafmutism  in  three  men  sbell-shocked  at  one  time Roussy,  1915 . . .  703 

499.  J 

500.  Vomiting;  incontinence,  abasia:  Cure  by  persuasion. .  .McDowell,  1916.705-706 

501.  Hysterical  convulsions  cured  by  an  explanation Hurst,  1917 .  . .  706 

502.  Course  of  a  case  with  crises  of  trembling Roussy,  1915 . . .  706 


672 

675 
676 
678 
679 


682 
683 

684 
685 
688 
690 
691 
692 

693 
694 

695 
696 
697 


699 
701 
702 


XXXIV 


TABLE    OF    CONTENTS 


Case 

503- \ 
504-/ 
505 


Two  cases  of  lameness  cured  by  persuasion Russel, 


506. 

507- 
S08. 

509- 
510. 

Sii- 
512. 

513- 
514- 


515- 
S16. 
517- 

518- 
519- 
520. 

521. 
522. 
523- 
524- 
525- 
526. 

527- 

528. 
529- 

530. 

531- 
532. 

533- 
534- 
535- 
536. 

537- 


Head  trauma:  Treatments  by  bandage,  isolation,  open  air  and  to- 

and-f ro  transfers Binswanger, 

Rationalization  of  war  memories Rivers, 

Same Rivers, 

Same Rivers, 

Same Rivers, 

Same,  without  redeeming  feature  as  nucleus  of  rationalization 

Rivers, 

Paraplegia  cured  by  removal  of  crutches Veale, 

Same Veale, 

Paraplegia:  Chocolates  versus  isolation , Buzzard, 

Blindness,    mutism,    deafness.     Immediate    spontaneous    recovery 
from  the  first;   gradual  recovery  from  second;  deafness  cured  by 

"  small  operation  " Hurst, 

Deafness:  Treatment  by  stimulating  vestibular  apparatus. 0'3/a//ey, 

Mutism:  Treatment  by  operative  manipulation Morestin, 

Visual  impairment:  Treatment  by  suggestion,  faradism  injections 

Mills, 

Aphonia:  Treatment  by  manipulation  in  larj-nx O^M alley, 

Same Vlasto, 

Mutism,  amnesia:  Treatment  by  faradism;  climatic  cure  in  dream 

Smyly, 

Blindness:  Cure  by  injections  in  temple Bruce, 

Deafness  cured  by  suggestion  in  writing Buscaino, 

Reproduction  of  Shell-shock  story  in  hypnosis :  Recovery ....  Myers, 

Same Myers, 

Automatism,  amnesia,  deaf  mutism:  Recovery  by  hypnosis..  .Myers, 

Mutism :  Recovery  by  h>-pnosis Hurst, 

Stammering:  Cure  by  hj^pnosis Hurst, 

Mutism  and  amnesia:  Cure  by  hypnosis Myers, 

Victoria  Cross  winner:   Bayonet  clutch  contracture  revealed  by  hyp- 
nosis   Eder, 

Contracture:  Hypnotic  cure  "indecently  quick" Nonne, 

"Doll's  head"  anesthesia:  Mutism:  Cure  by  h>pnosis Nonne, 

Aline  explosion:  Tremors  (also  ante  bellum  tremors):  Cure  by  hyp- 
nosis   Grilnbaum, 

Astasia-abasia:  Cure  by  h>pnosis Nonne, 

Crural  monoplegia:  Cure  by  hypnosis Hurst, 

Tremors  and  sensory  disorders:    Cure  by  h>'pnosis Nonne, 

Paraplegia   of  gradual  development:    Cure  by  repeated  hypnosis 

Nonne, 
Visual  impairment  and  dysbasia:  Cure  by  hypnosis Or^nond, 


Page 

I9I7 

..707 

I9IS 

..708 

I9I8 

..712 

I9I8 

•  713 

I9I8 

..714 

I9I8 

•  715 

I9I8 

.  .716 

I9I7 

..717 

I9I7 

..718 

I9I6 

..719 

I9I7 

..720 

I9I6 

..721 

I9I5 

.  .722 

I9I5 

•724 

I9I6 

■•72s 

I9I7 

•  •727 

I9I7 

..728 

I9I6 

■729 

I9I6 

•  •730 

I9I6 

•  •732 

I9I6 

•733 

I9I6 

•734 

I9I7 

•736 

191 7 

••737 

1916 

•739 

1916 

..741 

1915 

..742 

1915 

•■744 

1916 

•■745 

191S 

•■747 

1917 

..748 

1915 

■•749 

191S 

■751 

1915- 

. .  752 

TABLE   OF   CONTENTS  XXXV 

Case  Page 

538.  Blindness  cured  by  hypnosis Hurst,  1916. . .  753 

539.  Postoperative  retention  of  urine:  Relief  by  hypnosis. . .  .Podiapolsky,  1917. . .  754 

540.  Postoperative  pains:  Relief  by  hypnosis Podiapolsky,  1917.  . .  755 

541.  Stereo tjT^ed  war  dream  and  ante  helium  headache:  Cxire  by  hypnosis 

Riggall,  191 7...  756 

542.  Amnesia  and  ante  helium  headache:  Cure  by  hypnosis.  ..Biirmiston,  1917. .  .757 

543.  Convulsions  cured  by  hypnosis Hurst,  1917 . . .  759 

544.  Two  attacks  of  mutism:    Spontaneous  recovery  from  one  in  18 

months,  from  the  other  by  hypnosis Eder,  1916 .  . .  759 

545.  Neurasthenic  symptoms  cured  by  repeated  hypnosis Tomhleson,  191 7. . .  760 

546.  Neurasthenic    symptoms:   Improvement    under  repeated  hypnosis 

Tomblesofi,  1917.  ..761 

547.  Convulsions  "Jacksonian"  and  dysbasia:  Cure  by  hypnosis 

Tomhleson,  1917. .  .762 

548.  Agoraphobia:  Cure  by  hypnosis Hiirsf,  1917 . . .  763 

549.  Manual  tremors:  Treatment  by  forcing  and  isolation.  .  .Binswanger,  1915.  .  .764 

550.  Mutism:  Psychoelectric  cure Schoh,  1915 ...  766 

551.  Hemiplegia  and  deaf  mutism;   (also  convulsions  by  heterosuggestion) : 

Improvement  by  faradism;  full  recovery  by  suggestion,  ^rmrfe/w,  19 15 ...  767 

552.  Deafmutism,  cures,  relapses  and  eventual  cure  by  anesthesia 

Dawson,  1916.  .  .768 

553.  Deafness:  Cure  by  suggestion  on  emerging  from  ether Bruce,  1916 ...  770 

554.  Aphasia,  hemiplegia,  hemianesthesia,  and  (by  medical  suggestion) 

trismus:  Cure  by  anesthesia  and  suggestion Arinstein,  1915 .  . .  771 

555.  Triplegia,    mutism,   jumping-jack   reactions:    Cure   by   anesthesia, 

verbal  suggestion,  faradism Arinstein,  1915. . .  773 

556.  Mutism  and  musical  alexia:  Cure  by  anesthesia Proctor,  1915   .   775 

557.  Deafmutism:  Deafness  cured  by  anesthesia Gradenigo,  1917. . .  776 

^,  '  \  Interaction  of  two  cases  (deafmute  and  mute)  under  treatment 

Smyly,  1917...777 

560.  Dysbasia:  Cure  by  stovaine  anesthesia Claude,  191 7. .  .778 

561.  Same Claude,  1917.  . .  779 

562.  Deafmutism Bdlin,  Vernet,  1917 .  . .  780 

563.  Monoplegia:   Cure  by  electricity  administered  with  a  bored  and 

authoritative  look Adrian,  Yeallatid,  1917 .  . .  782 

564.  Monoplegia   after   sling:    Technique   of   electrical   suggestion  and 

"rapid"  reeducation Adrian,  Yealland,  1917.  . .  783 

565.  Hysterical  "sciatica":  Treatment  by  faradism  and  verbal  suggestion 

Harris,  1915 .  . .  785 

566.  Prognosis  of  intensive  reeducation  in  reflex  (physiopathic)  disorder 

Vincent,  1916.  .  .786 
567-  Hysterical  contracture  (with  physiopathic  features)  brutally  con- 

Q^ered Ferrand,  1917.  . . 788 


XXXvi  TABLE    OF    CONTENTS 

Case  Page 

568.  Paraparesis:  Cure  by  exercises  electrically  provoked Turrell,  1915 . . .  790 

569.  Astasia-abasia:  (" Lourdes-like "  cure) Voss,  1916.  . .  791 

570.  Abasia:  Rapid  cure Schultze,  1916 .  . .  792 

571.  Heterosuggestive  brachial  paresis:   Electric  suggestion  and  recovery 

in  five  days Hewat,  1917.  . .  794 

572.  Contracture  of  right  index  finger  and  thumb:  Psychoelectric  cure 

Roussy,  L'Hermitte,  1917. . .  795 

573.  Brachial  monoplegic  able  to  descend  ladder  with  arms  only. .  .Claude,  1916.  . .  795 

574.  Brachial  monoparesis:  Vicissitudes  of  treatment Vincent,  1917 . . .  796 

575.  Paresis  and  sensory  disorder:  Reeducation Binswanger,  1915 . . .  798 

576.  Seizures  (of  ante  bellum  origin),  astasia-abasia,  anesthesias:   Reedu- 

cation   Binswanger,  1915 .  . .  800 

577.  Progress  in  case  of  paresis  of  foot  and  spasticity  of  hip. .  Binswanger,  1915 .  . .  805 

578.  Mutism  (Reeducation) Briand,  Philippe,  1916.  .  .808 

579.  Stammering:   Isolation  and  reeducation Binswanger,  1915 .  . . 810 

580.  Deafmutism:  Phonetic  reeducation Liebault,  1916.  .  .814 

581.  Aphonia:  Pressure  on  sternum  and  respiratory  gymnastics — Garel,  1916 .  .  .816 

582.  Stammering:  Reeducation MacMahon,  1917.  .  .817 

583.  Speech  disorder:  Reeducation MacMahon,  1917. .  .818 

584.  Camptocormia:  Psycho-electric  cure:  lameness  cured  by  reeducation 

Roussy,  VHermitte,  1917.  .  .819 

585.  Deafmutism:  Speechrecovery  by  suggestion  and  reeducation:  Hear- 

ing by  reeducation Liebault,  1916 ...  822 

586.  Mutism;  stammering;  Reeducation;  hypnosis MacCurdy,  1917.  .  .823 

587.  Anesthesias:    Spontaneous  gradual     recovery:    "Paralysis"   cured 

by  reeducation Binswanger,  1915  .  . .  824 

588.  Deafmutism;  head  movements,  anesthesia:  Cure  by  faradism,  mas- 

sage and  reeducation Arinstein,  1916  . . .  827 

589.  Amnesia  and  paralysis:  Reeducation Batten,  1916. .  .828 

SECTION  E.     EPICRISIS 

paragraph 

Terminology 1-8 

Diagnostic  Delimitation  Problem 9-39 

The  Nature  of  War  Neuroses 4o-74 

Diagnostic  Differentiation  Problem 75~99 

General  Nature  of  Shell-shock 89-102 

Treatment:  General  Observations 103-114 


La  divina  giustizia  di  qua  punge 
quell'  Attila  che  fu  flagello  in  terra. 

Divine  justice  here  torments  that  Attila,  who 
was  a  scoiu-ge  on  earth. 

Inferno,  Canto  xii,  133-134. 


A.   PSYCHOSES   INCIDENTAL   IN  THE  WAR 

The  data  from  all  the  belligerent  countries,  collected  in 
this  book,  go  far  to  prove  that,  whatever  at  last  you  elect 
to  term  Shell-shock,  you  must  pause  to  consider  whether  your 
putative  case  is  not  actually: 

A  matter  of  spirochetes? 

The  response  of  a  subnormal  soldier? 

An  equivalent  of  epilepsy? 

An  alcoholic  situation? 

A  result  of  neurones  actually  hors  de  combat  ? 

A  state  of  bodily  weakness  (perhaps  of  faiblesse  irritable)  ? 

A  bit  of  dementia  praecox? 

One  of  the  ups  and  downs  of  the  emotional  (affective, 
cyclothymic)  psychoses? 

An  odd  psychopathic  reaction  in  which  the  response  is 
abnormal  not  so  much  by  reason  of  excessive  stimulus  as 
by  reason  of  defective  power  of  response? 

On  a  simpler  basis,  is  not  our  Shell-shocker  just  a  banal 
example  of  hysteria,  neurasthenia,  psychasthenia;  and  is  not 
this  psychoneurotic  more  peculiar  in  his  capacity  to  be 
shocked  than  are  the  conditions  that  purvey  the  shocks? 

Put  more  concretely  in  the  terms  of  available  tests  and 
criteria,  open  to  the  psychiatrist,  does  not  every  putative 
Shell-shock  soldier  deserve  at  some  stage  a  blood  test  for 
syphilis?  Should  we  not  be  reasonably  sure  we  are  not  fac- 
ing a  man  inadequate  to  start  with,  so  far  as  mental  tests 
avail?  Should  we  not  verify  (even  at  considerable  expense 
of  time  and  money  by  so-called  "social  service  "  methods) 
the  facts  of  epilepsy  and  epileptic  taint?  Of  alcoholism? 
And  so  on?    There  can  be  no  two  answers  to  these  questions. 

Upon  the  following  page  is  a  practical  grouping  of  mental 
diseases,  devised  in  the  first  place,  not  for  war  psychoses,  but 
for  the  initial  sifting  of  psychopathic  hospital  cases.     Now 


2  PSYCHOSES 

the  psychopathic  hospital  group  of  cases  constitutes  in  peace 
practice  the  closest  analogue  of  the  mental  cases  met  in  active 
military  practice,  because  the  "incipient,  acute,  and  curable"* 
cases,  for  which  psychopathic  hospitals  are  built  and  which 
flock  to  or  are  sent  to  the  wards  and  outdoor  departments  of 
such  hospitals,  are  precisely  the  cases  that  early  come  forward 
in  active  military  practice.  They  are  precisely  the  cases  in 
which  that  pathological  event  —  whatever  it  is  —  we  know 
as  Shell-shock  may  be  expected  to  develop.  It  is  precisely 
the  "incipient,  acute,  and  curable "  instances  of  mental 
disease  which  we  hope  to  exclude  from  our  American  army  by 
cis-Atlantic  winnowing-out  at  the  hands  of  neuropsychiatric 
experts  —  the  best  preventive  we  hope  both  of  Shell-shock 
and  of  other  worse  mental  conditions,  if  such  there  be.  Mili- 
tary mental  practice  plainly  deals,  not  so  much  with  frank  and 
committable  insanity,  as  with  mental  diseases  of  a  medically 
milder  but  a  militarily  far  more  insidious  nature. 

A  further  inspection  of  this  grouping  of  mental  diseases 
shows  not  only  that  it  contains  many  conditions  not  usually 
termed  "insanity  "  (such  as,  e.g.,  feeblemindedness,  epilepsy, 
alcoholism,  sundry  somatic  diseases,  psychoneuroses) ,  but 
that  these  conditions  are  presented  for  practical  purposes  in 
a  certain  seemingly  arbitrary  order.  Without  attempting 
to  justify  this  selection  of  scope  (not  too  wide  for  modern 
psychiatry,  most  would  readily  acknowledge),  I  shall  draw 
out  a  little  further  what  I  consider  to  be  the  virtues  of  the 
order  selected.  In  the  first  place,  all  will  concede,  some  order 
of  consideration  of  collected  data  is  a  prime  necessity  to  the 
tyro.  Without  an  order  of  consideration  the  diagnostic  tyro 
is  but  too  apt  to  find  in  the  best  textbooks  of  psychiatry 
(even  more  easily  the  better  the  textbook)  all  he  needs  to 
prove  that  the  case  in  hand  is  —  almost  anything  he  selects 
to  make  his  case  conform  to!  And  how  much  more  danger- 
ous this  debating-society  method  of  diagnosis  (by  choice  of 
a  side  and  matching  a  textbook  type)  may  become  in  the  fluid 
and  elastic  conditions  of  psychopathic  hospital  practice,  can 

*  Official  phrase  for  the  scope  of  the  Psychopathic  Hospital, 
Boston,  Massachusetts. 


PSYCHOSES 


PRACTICAL   GROUPING   OF  MENTAL  DISEASES 

The  order  adopted  for  these  groups  (which  roughly  correspond  to  botani- 
cal or  zoological  orders)  is  a  pragmatic  order  for  successive  exclusion  on  the 
basis  of  available  tests,  criteria,  or  information:  the  actual  diagnosis  is  a 
product  of  still  further  differentiation  within  the  several  groups. 

The  case-histories  of  this  book  will  show  that 

{a)  most  shell-shock  is  in  group  X,  Psychoneuroses, 

(ft)  the  diagnostic  delimitation  problem  is  chiefly  against  I.  Syphilo- 
psychoses,  III.  Epileptoses,  VI.  Somatopsychoses, 

(c)  the  finer  differentiation  problem  is  between  X.  Psychoneuroses  and 
V.    Encephalopsychoses.     (See  Epicrisis,  propositions  9-12,  40-43,  72-73.) 


I.    Syphilitic  Psychoses 
1 1 .   Feeblemindedness 

III.  Epilepsy 

IV.  Alcoholic,     Drug,     and     Poison 

Psychoses 

V.   Focal  Brain  Lesion  Psychoses. 

VI.   Symptomatic      (Somatic)      Psy- 
choses 

VII.    Presenile-Senile  Psychoses 

VIII.    Dementia    Praecox    and    Allied 
Psychoses 

IX.    Manic-Depressive     and     Allied 
Psychoses 

X.    Psychoneuroses 

XI.   Other  Forms  of  Psychopathia 


SYPHILOPSYCHOSES 

HYPOPHRENOSES 

EPILEPTOSES 

PHARMACOPSYCHOSES 
ENCEPHALOPSYCHOSES 

SOMATOPSYCHOSES 
GERIOPSYCHOSES 

SCHIZOPHRENOSES 

CYCLOTHYMOSES 

PSYCHONEUROSES 

PSYCHOPATHOSES 


Chart  1 


A  PSYCHOSES 

readily  be  observed  by  one  who  contemplates  the  formes 
frustes  and  entity-sketches  that  the  "incipient,  acute,  and 
curable  "  group  of  cases  presents. 

No  conclusions  are  intended  to  be  drawn  in  these  introduc- 
tory pages.  Such  conclusions  as  are  risked  are  placed  in  the 
Epicrisis  (see  Section  E).  But  so  much  can  be  said:  If 
we  are  ever  to  surround  the  problem  of  Shell-shock  {intra 
bellum  or  post  helium),  we  must  approach  it  with  no  artificial 
and  CL  priori  limitations  of  its  scope.  We  must  not  even 
agree  beforehand  that  Shell-shock  is  nothing  but  psycho- 
neurosis:  that  would  be  a  deductive  decision  unworthy  of 
modern  science.  In  the  collection  of  these  cases,  I  have  tried 
to  place  the  topic  upon  the  broadest  clinical  base.  Samples 
of  virtually  every  sort  of  mental  disease  and  of  several  sorts 
of  nervous  disease  have  been  laid  down,  some  obviously  not 
instances  of  Shell-shock,  some  mixed  with  clinical  phenomena 
of  Shell-shock,  others  hard  to  tell  offhand  from  Shell-shock  — 
the  whole  on  the  basis  that  we  shall  earliest  learn  what 
Shell-shock,  the  pathological  event,  is  by  studying  what  it 
is  not.  As  the  sequel  may  show,  we  are  perhaps  not 
entitled  to  regard  Shell-shock,  the  pathological  event,  as 
always  associated  with  shell-shock,  the  physical  event.  We 
shall,  therefore,  find  in  Section  A  (see  tables  on  pages  6 
and  7. 

(i)  Cases  without  either  physical  shell-shock,  or  patho- 
logical Shell-shock  —  psychoses  of  various  kinds  incidental 
in  the  war  ( V). 

(2)  Cases  with  physical  shell-shock  but  without  patho- 
logical Shell-shock  —  psychoses  of  various  kinds  seemingly 
liberated  by,  aggravated  by,  or  accelerated  by  the  physical 
factor  of  shell-shock  (+  -  +). 

(3)  Cases  without  physical  shell-shock  but  with  both 
symptoms  of  pathological  Shell-shock  as  well  as  of  other 
psychosis  (—  +-}-). 

(4)  Cases  with  physical  shell-shock,  with  clinical  phe- 
nomena of  Shell-shock,  as  well  as  of  other  psychosis  (+  +  +)• 


PSYCHOSES  5 

At  the  end  of  Section  A,  accordingly,  we  shall  be  left  with 
two  more  formulae  for  discussion  in  Sections  B,  C,  and  D,  viz: 

(5)  Cases  without  physical  shell-shock  but  with  symptoms 
of  pathological  Shell-shock  (—  +  — ). 

(6)  Cases  with  physical  shell-shock  and  pathological  Shell- 
shock  (  +  +  -). 

The  data  of  Section  A  will  solidly  prove  that  Shell-shock, 
however  picturesque  the  term  for  laymen  or  in  the  argot  of 
the  clinic,  is  medically  most  intriguing.  As  we  cannot  get 
rid  of  the  term  (even  by  suppressing  it  in  parentheses  or  by 
condemning  it  to  the  limbo  of  the  so-called),  we  must  make 
the  best  of  it  by  calling  Shell-shock  just  the  ore  in  the  clinical 
mine.  To  say  the  least,  the  term  is  harmless :  it  merely  stimu- 
lates the  lay  hearer  to  questions.  These  questions  he  must 
ask  of  the  expert.  But  every  time  that  the  expert  suavely 
states  that  Shell-shock  is  nothing  but  psychoneurosis,  that 
expert  runs  the  risk  of  hurting  some  patient|who  may  or  not 
have  a  psychoneurosis  but  has  been  called  psychoneurotic. 
All  the  while,  of  course,  the  suave  expert  is  perfectly  right  — 
statistically.  In  fine,  the  man  you  have  called  a  victim  of 
Shell-shock  is  probably  a  victim  of  psychoneurosis,  but  only 
probably  ! 

Section  A  shows  how  he  may  —  not  probably,  but  possibly 
—  be  a  victim  of  say  ten  other  things.  But  it  is  not  that  he 
has  an  even  chance  of  being  one  of  these  ten  other  things. 
As  the  reader  watches  the  procession  of  cases  in  Section  A, 
he  will  perceive  that,  amongst  the  ten  major  groups  there 
studied,  some  have  far  greater  diagnostic  likelihood  than 
others.  Thus,  syphilis,  epilepsy,  and  somatic  diseases  will  in 
the  sequel  prove  more  dangerous  to  our  success  as  diagnos- 
ticians than,  e.  g.,  feeblemindedness  or  even  perhaps  alcohol- 
ism. But  now  let  us  look  at  these  cases  systematically,  just 
as  if  we  dealt  with  so  many  cases  of  Railway-spine  or  any 
other  "incipient,  acute,  and  curable"  cases. 


PSYCHOSES 


PSYCHOPATHIA  MARTIALIS 


I  I  \ 

SHELL-SHOCK  SHELL-SHOCK  PSYCHOSIS 

(the  physical  fac-      (neurotic  symptoms)       (symptoms  non- 
tor)  neurotic) 

Absent  Absent  INCIDENTAL 

Present  Absent  LIBERATED, 

AGGRAVATED, 

ACCELERATED 

PSYCHOSES 


Absent 


Present 


Absent 


Present 


COMBINED  NEUROSES 
AND   PSYCHOSES 

*  (Formula — (-+) 

COMBINED  NEUROSES 

AND    PSYCHOSES 

(Formlxa  +  +  +) 

NEUROSES 
(Quasi  Shell-shock) 

NEUROSES 
(True  Shell-shock) 


Absent 


Absent 


For  formulae  see  Chart  3  on  opposite  page. 


Chart  2 


PSYCHOSES 


PSYCHOPATHIA  MARTIALIS 

FORMULAE 

1 

1 

S,  N,  P*  =   SHELL-SHOCK         SHELL-SHOCK 

PSYCHOSIS 

(the  PHYSICALf          (neurotic  SYMPTOMS) 
factor)  PRESENT                     PRESENT 

P  =                            - 

(non-neurotic 
symptoms)  pres- 
ENT 
+ 

SP  =                   + 

+ 

NP  =                    -                                 + 

+ 

SNP  =4-                                + 

+ 

N=                   -                                + 

- 

SN=                   +                                + 

- 

*  In  the  literal  formulae,  S  =  Shell-shock,  N  =  Neurosis 

;,  P  =  Psychosis. 

t  These  plus-or-minus  formulae  are  not   intended  to 
physical  factor,  where  present  (+),  must  have  worked 
upon  the  nervous  system:    the  effects  of  the  physical 
wholly  emotional  or  otherv/ise  psychic. 

imply  that  the 
a  physical  effect 
factor  might  be 

Ch*rt  3 

I.   SYPHILOPSYCHOSES 
(SYPHILITIC   GROUP) 


An  officer  of  high  rank  deserts  his  command  in  a 
crisis:  alienists'  report. 


Case  I.     (Briand,  February,  1915.) 

M.  X.  was  an  officer  ranking  high  in  the  French  army, 
having  miUtary  duties  of  a  critical  nature  and  of  great  im- 
portance (social  reasons  forbid  Briand's  giving  informatory 
details).  Suffice  it  to  say  that  he  was  brought  before  court- 
martial  for  abandoning  his  post  at  the  very  moment  when 
his  presence  was  most  urgently  required.  He  turned  tail, 
without  taking  the  most  elementary  military  precautions. 

M.  X.  was  passed  up  to  alienists.  He  was  not  a  case  of 
Shell-shock  unless  of  the  anticipatory  sort.  He  was  somati- 
cally run-down  and  of  lowered  morale  and  now  65  years  of  age. 
The  campaign  had  been  fatiguing. 

The  alienists  decided  that  the  officer  had  not  been  respon- 
sible for  his  non-military  acts.  He  had  been,  they  found,  in 
a  state  of  mental  confusion  at  the  time  of  desertion,  such  that 
amnesia  for  his  duties  and  heedlessness  of  consequences  had 
allowed  him  to  leave  the  front  without  looking  behind  him 
or  securing  substitution.  This  state  of  mental  confusion  had 
been  preceded  by  overwork  and  several  nights  of  insomnia. 

Moreover  he  was  palpably  arteriosclerotic.  Blood  pressure 
was  high.  The  history  was  one  of  slight  shocks  and  a  mild 
hemiplegia.  The  confusion  at  the  front  was  only  the  most 
recent  of  a  series  of  transitory  attacks  of  confusion.  At  the 
time  of  examination  this  high  officer  was  actually  in  a  state 
of  mild  dementia. 

M.  X.  was  an  old  colonial  man,  malarial,  and  had  been  a 
victim  of  syphilis. 


SYPHILOPSYCHOSES 

A  naval  officer    sees    hundreds    of    submarines: 
General  paresis. 


Case  2.     (Carlill,  Fildes,  and  Baker,  July,  191 7.) 

A  naval  officer,  36,  during  August,  19 16,  asserted  that  he 
could  see  hundreds  of  submarines.  At  one  time  he  imagined 
that  he  was  receiving  trunk  calls  in  the  middle  of  the  ocean. 
He  was  admitted  to  Haslar,  and  the  Wassermann  reaction 
of  the  serum  was  found  strongly  positive.  The  spinal  fluid 
was  not  at  this  time  examined.  The  officer  recovered  to 
some  extent,  was  given  no  special  treatment,  and  was  sent 
on  leave. 

He  came  under  observation  again  in  October,  191 6,  having 
become  very  strange  in  his  manner,  on  one  occasion  passing 
water  into  the  coal  box,  and  talked  about  impending  elec- 
trocution. His  ankle- jerks  were  found  sluggish  and  there 
was  a  patch  of  blunting  to  pin  pricks.  The  diagnosis  of 
general  paresis  was  made.  The  spinal  fluid  was  afterward 
examined  and  found  to  be  negative  to  the  Wassermann 
reaction  but  contained  15  lymphocytes  per  cubic  mm. 

Three  full  doses  of  Kharsivan  freed  him  from  delusions  and 
left  him  apparently  absolutely  sane.  It  was  recommended 
that  he  should  be  kept  at  Haslar  to  continue  treatment. 
However,  he  had  been  certified  insane  and  was  therefore  sent 
to  Yarmouth,  from  which  he  was  discharged  in  February, 
19 1 7,  having  been  in  good  mental  health  throughout  his  stay 
there. 

Re  syphilis  and  general  paresis  of  military  officers,  as  in 
Cases  I  and  2,  Russo-Japanese  experience  was  already  at 
hand.  Autokratow  saw  paretic  Russian  officers  sent  to  the 
front  in  early  but  still  obvious  phases  of  disease.  These 
paretics  and  various  arteriosclerotics,  Autokratow  saw  back 
in  Russia  in  the  course  of  a  few  months. 

Re  naval  cases,  see  also  Case  5  (Beaton).  Beaton  thinks 
that  monotonous  ship  duty,  alternating  with  critical  stress 
of  service,  bears  on  morale  and  liberates  mental  disorder. 


10  SYPHILOPSYCHOSES 


Neurosyphilis   may  be   aggravated  or  accelerated 
under  war  conditions. 


Case  3.     (Weygandt,  May,  191 5.) 

A  German,  long  alcoholic  and  thought  to  be  weakminded, 
volunteered,  but  shortly  had  to  be  released  from  service. 
He  began  to  be  forgetful  and  obstinate,  cried,  and  even 
appeared  to  be  subject  to  hallucinations.  The  pupils  were 
unequal  and  sluggish.  The  uvula  hung  to  the  right.  The 
left  knee-jerk  was  lively,  right  weak.  Fine  tremors  of  hands. 
Hypvalgesla  of  backs  of  hands.  Stumbling  speech.  Atten- 
tion poor. 

It  appeared  that  he  had  been  infected  with  syphilis  in  188 1 
and  in  1903  had  had  an  ulcer  of  the  left  leg. 

The  military  commission  denied  that  his  service  had 
brought  about  the  disease. 

Case  4.     (Hurst,  April,  1917.) 

An  English  colonel  thought  himself  perfectly  fit  when  he 
went  out  with  the  original  Expeditionary  Force.  He  had  had 
leg  pains,  regarded  as  due  to  rheumatism  or  neuritis.  He 
w^as  invalided  home  after  exhaustion  on  the  great  retreat. 
He  was  now  found  to  be  suffering  from  a  severe  tabes.  He 
improved  greatly  under  rest  and  antisyphilitic  treatment. 
He  has  now  returned  to  duty. 

Case  5.     (Beaton,  May,  1915.) 

An  apparently  healthy  man,  serving  on  an  English  battle- 
ship, severed  a  tendon  in  a  finger.  The  injury  was  regarded 
as  minor.  The  tendon  was  sutured  and  the  wound  healed. 
During  the  man's  convalescence  he  was  accidentally  discovered 
to  have  an  Argyll -Robertson  pupil  and  some  excess  reflexes. 
Neurosyphilis  had  probably  antedated  the  accident.  But 
from  the  moment  of  this  trivial  injury,  the  disease  advanced 
rapidly. 


SYPHILOPSYCHOSES  1 1 


Overwork  in  service ;  several  months  exacting  work 
well  performed :  General  paresis. 


Case  6.    (Boucherot,  1915.) 

A  lieutenant  of  Territorials,  aged  41  (heredity  good,  anal 
fistula  at  30,  with  ulceration  of  penis  of  an  unknown  nature 
at  the  same  period).  In  1907  when  off  service  and  married, 
his  wife  gave  birth  to  a  child ;  no  miscarriages.  Had  been  a 
good  soldier  in  service  before  the  war.  The  lieutenant  was 
called  to  the  colors  August  2,  19 14,  and  was  detached  for 
special  duty,  for  the  performance  of  which  he  was  much 
praised  by  the  commanding  officers.  The  work,  however, 
was  too  much  for  him  and  on  April  i  he  had  to  be  evacuated 
to  the  hospital  with  a  ticket  saying  "Nervous  depression 
following  overwork  in  service."  On  April  14  he  seemed  well 
enough  for  a  convalescent  camp,  but,  apparently  through 
red  tape,  was  sent  to  a  hospital  at  Orleans,  On  June  23  he 
had  to  be  evacuated  to  the  Fleury  annex.  His  eyes  were  dull 
and  features  flaccid;  his  whole  manner  suggested  fatigue. 
His  pupils  were  myotic,  tongue  tremulous,  speech  slow  and 
stumbling.  Knee-jerks  were  exaggerated  and  gait  difficult, 
the  right  leg  dragging.  Headaches.  He  could  not  perform 
the  slightest  intellectual  work  and  was  the  victim  of  retro- 
grade and  anterograde  amnesia.  He  was  aware  of  the  decline 
of  his  mental  power  and  was  fain  to  struggle  against  it, 
becoming  restless  and  sad.  The  gaps  in  his  memory  grew 
deeper,  he  became  more  and  more  impulsive,  even  violent, 
and  had  spells  of  excitement.  Dizziness  and  palpitation 
developed.  Sometimes  there  were  auditory  and  visual 
hallucinations  of  such  intense  character  that  he  tried  feebly 
to  commit  suicide  with  a  penknife.  He  fell  into  semicoma, 
and  then  had  a  number  of  apoplectiform  attacks,     W.  R.  4- 

Apparently  the  moral  and  physical  situation  of  the  lieu- 
tenant was  absolutely  normal  when  the  campaign  began  and, 
as  he  fulfilled  detail  duties  with  absolute  correctness  for  a 
number  of  months,  Boucherot  argues  that  here  is  an  instance 
of  general  paresis  dedanche  by  overwork. 


12  SYPHILOPSYCHOSES 


Syphilis    contracted    before    enlistment.     Neuro- 
syphilis aggravated  by  service. 


Case  7.     (Todd,  personal  communication,  1917.) 

A  laboring  man,  42,  who  always  strenuously  denied  syphi- 
litic infection,  proceeded  to  France  eight  months  after  enlist- 
ment. He  had  not  been  in  France  three  weeks  when  he 
dropped  unconscious.  He  regained  consciousness,  but  re- 
mained stupid,  dull  in  expression,  and  with  memory  impaired. 
His  speech  was  also  impaired.  There  was  dizziness  and  a 
right-sided  hemiplegia. 

He  was  confined  to  bed  four  months  and  was  then  "boarded" 
for  discharge. 

Physically,  his  heart  was  slightly  enlarged  both  right  and 
left;  sounds  Irregular;  extra  systoles;  aortic  systolic  murmur 
transmitted  to  neck;  blood  pressure  140:40.  Precordial 
pain,  dyspnoea. 

Neurologlcally,  there  was  a  partial  spastic  paralysis  of  the 
right  thigh  which  could  be  abducted,  could  be  flexed  to  120°, 
and  showed  some  power  in  the  quadriceps.  There  was  also 
a  spastic  paralysis  of  the  right  arm,  but  the  shoulder  girdle 
movements  were  not  Impaired.  There  was  a  slight  weakness 
on  the  right  side  of  the  face.  There  was  no  anesthesia 
anywhere. 

The  deep  reflexes  were  increased  on  the  right  side,  Babinski 
on  right,  flexor  contractures  of  right  hand,  extensor  contrac- 
tures of  right  leg,  abdominal  and  epigastric  reflexes  absent, 
pupils  active,  tongue  protruded  in  straight  line. 

Fluid :  slight  Increase  in  protein.     W.  R.   +  +  + 

The  Board  of  Pension  Commissioners  ruled  that  the  condi- 
tion had  been  aggravated  hy  service  (not  "  on  service  "). 

Re  general  paresis,  Fearnsldes  suggested  at  the  Section  of 
Neurology  in  the  Royal  Society  of  Medicine  early  In  1916, 
that  In  all  cases  of  suspected  Shell-shock  the  Wassermann 
reaction  of  the  serum  should  be  determined,  and  went  on  to 
say  that  cases  of  so-called  Shell-shock  with  positive  W.  R. 
often  improve  rapidly  with  antisyphllltic  remedies. 


SYPHILOPSYCHOSES  1 3 

Duration  of  neuro syphilitic  process  important  re 
compensation. 


Case  8.     (Farrar,  personal  communication,  191 7.) 

A  Canadian  of  36  enlisted  in  191 5,  served  in  England,  and 
was  returned  to  Canada  in  February,  191 7,  clearly  suffering 
from  some  form  of  neurosyphilis  (W.  R.  positive  in  serum 
and  fluid,  globulin,  pleocytosis  108). 

There  is  no  record  of  any  disability  or  symptom  of  nervous 
or  mental  disease  at  enlistment.  The  first  symptoms  were 
noted  by  the  patient  in  May,  191 6,  six  months  or  more  after 
enlistment.  The  case  was  reviewed  at  a  Canadian  Special 
Hospital,  October  11,  19 16,  by  a  board  which  reported: 

"The  condition  could  only  come  from  syphilitic  infection 
of  three  years'  standing  "  (a  decision  bearing  on  compensa- 
tion) ;  but  the  general  diagnosis  remained : 

"Cerebrospinal  lues,  aggravated  by  service." 

The  picture  which  the  medical  board  regarded  as  of  at  least 
three  years*  standing  was  as  follows : 

History  of  incontinence,  shooting  pains,  attacks  of  syncope, 
general  weakness,  facial  tremor,  exaggerated  knee-jerks, 
pupils  react  with  small  excursion.  Speech  and  writing  dis- 
order, perception  dull,  lapses  of  attention,  memory  defect, 
defective  insight  into  nature  of  disorder,  emotional  apathy. 

1.  Was   the   conclusion    "aggravated   by   service "   sound? 

On  humanitarian  grounds  the  victim  is  naturally  con- 
ceded the  benefit  of  the  doubt.  But  it  is  questionable 
how  scientifically  sound  the  conclusion  really  was. 

2.  Could  the  condition  come  only  from  syphilitic  infection 

of  at  least  three  years'  standing?  Hardly  any  single 
symptom  in  this  case  need  be  of  so  long  a  standing ;  yet 
the  combination  of  symptoms  seems  by  very  weight  of 
numbers  to  justify  the  conclusion  of  the  medical  board. 

Farrar's  case  and  thirteen  others  of  "  Neurosyphilis  and 
the  War"  were  included  in  a  general  work  on  Neurosyphilis 
(Case  History  Series,  191 7,  Southard  and  Solomon).  For 
military  syphilis  In  general,  see  Thibierge's  Syphilis  dans 
VArmee  (also  in  translation). 


14  SYPHILOPSYCHOSES 


General  paresis  lighted  up  by  the  stress  of  military 
service  without  injury  or  disease? 


Case  9.     (Marie,  Chatelin,  Patrikios,  January,  1917.) 

In  apparently  good  health  a  French  soldier  repaired  to  the 
colors,  in  August,  1914,  being  then  23  years  old. 

Two  years  later,  August,  191 6,  symptoms  appeared: 
speech  disorder  with  stammering,  change  of  character  (had 
become  easily  excitable),  stumbling  gait.  He  became  more 
and  more  preoccupied  with  his  own  affairs,  grew  worse,  and 
was  sent  to  hospital  in  October,  19 16. 

He  was  then  foolish  and  overhappy,  especially  when  inter- 
viewed. There  was  marked  rapid  tremor  of  face  and  tongue. 
Speech  hesitant,  monotonous,  and  stammering  to  the  point 
of  unintelligibiUty.  His  memory,  at  first  preserved,  became 
impaired  so  that  half  of  a  test  phrase  was  forgotten.  Simple 
addition  was  impossible  and  fantastic  sums  would  be  given 
instead  of  right  answers.  Handwriting  tremulous,  letters 
often  missed,  others  irregular,  unequal,  and  misshapen. 

Excitable  from  onset,  the  patient  now  became  at  times 
suddenly  violent,  striking  his  wife  without  provocation. 
After  visit  at  home,  he  would  forget  to  return  to  hospital. 
Often  he  would  leave  hospital  without  permission  (of  course 
the  more  surprising  in  a  disciplined  soldier).     No  delusions. 

Serum  and  fluid  W.  R.  positive;   albumin;  lymphocytosis. 

Neurological  examination:  Unequal  pupils,  slight  right- 
side  mydriasis,  pupils  stiff  to  light,  weakly  responsive  in 
accommodation,  reflexes  lively,  fingers  tremulous  on  exten- 
sion of  arms. 

The  patient  had,  December  5,  19 16,  an  epileptiform  attack 
with  head  rotation,  limb-contractions  and  clonic  movements. 
Should  this  soldier  recover  for  disability  obtained  in  service? 
Marie  was  inclined  to  think  military  service  in  part  responsible 
for  the  development  of  the  paresis.  Laignel-Lavastine 
thought  so  also,  but  that  the  amount  assigned  should  be  5%- 
10%  of  the  maximum  assignable. 


SYPHILOPSYCHOSES  1 5 


SYPHILITIC  ROOT-SCIATICA  (lumbosacral 
radiculitis)  in  a  fireworks  man  with  a  French  artil- 
lery regiment. 


Case  10.     (Long  (Dejerine's  clinic),  February,  1916.) 

No  direct  relation  of  this  example  of  root-sciatica  to  the 
war  is  claimed  nor  was  there  a  question  of  financial  reparation. 

There  was  no  prior  injury.  At  the  end  of  March,  1915, 
the  workman  was  taken  with  acute  pains  in  lumbar  region 
and  thighs,  and  with  urgent  but  retarded  micturition. 

Unfit  for  work,  he  remained,  however,  five  months  with  the 
regiment,  and  was  then  retired  for  two  months  to  a  hospital 
behind  the  lines.  He  reached  the  Salpetriere  October  12, 
1915,  with  "double  sciatica,  intractable." 

There  was  no  demonstrable  paralysis  but  the  legs  seemed 
to  have  "melted  away,"  fondu,  as  the  patient  said.  Pains 
were  spontaneously  felt  In  the  lumbar  plexus  and  sciatic 
nerve  regions,  not  passing,  however,  beyond  the  thighs. 
These  pains  were  more  intense  with  movements  of  legs;  but 
coughing  did  not  Intensify  the  pains.  Neuralgic  points  could 
be  demonstrated  by  the  finger  In  lumbar  and  gluteal  regions 
and  above  and  below  the  iliac  crests  (corresponding  with 
rami  of  first  lumbar  nerves).  The  inguinal  region  was 
involved  and  the  painful  zone  reached  the  sciatic  notch  and 
the  upper  part  of  the  posterior  surface  of  the  thigh. 

The  sensory  disorder  had  another  distribution,  objectively 
tested.  The  sacral  and  perineal  regions  were  free.  Anes- 
thesia of  inner  surfaces  of  thighs,  hypesthesia  of  the  anterior 
surfaces  of  thighs  and  lower  legs.  The  anesthesia  grew  more 
and  more  marked  lower  down  and  was  maximal  in  the  feet, 
which  were  practically  insensible  to  all  tests,  including  those 
for  bone  sensation.  There  was  a  longitudinal  strip  of  skin 
of  lower  leg  which  retained  sensation. 

Position  sense  of  toes,  except  great  toes,  was  poor.  There 
was  a  slight  ataxia  attributable  to  the  sensory  disorder  — 
reflexes  of  upper  extremities,  abdominal,  and  cremasteric 
preserved,  knee-jerks,  Achilles  and  plantar  reactions  absent. 


1 6  SYPHILOPSYCHOSES 

The  vesical  sphincter  shortly  regained  its  function,  though 
its  disorder  had  been  an  initial  symptom.     Pupils  normal. 

The  "sciatica"  here  affects  the  lumbosacral  plexus. 

As  to  the  syphilitic  nature  of  this  affection,  there  had  been 
at  eighteen  (22  years  before)  a  colorless  small  induration  of 
the  penis,  lasting  about  three  weeks.  There  was  now  evident 
a  small  oval  pigmented  scar.  The  patient  had  married  at 
20  and  had  had  three  healthy  children. 

The  lumbar  puncture  fluid  yielded  pleocytosis  (120  per 
cmm.).      ■Mercurial  treatment  was  instituted. 

The  treatment  has  not  reduced  the  pains.  Long  thinks  it 
was  undertaken  too  long  (six  months)  after  onset.  The 
warning  for  early  diagnosis  is  manifest.  There  was  somehow 
a  delay  under  the  medical  conditions  of  the  army. 

Re  syphilis  in  munition-workers  Thibierge  has  much  to 
say  of  French  conditions.  Throughout  his  work  on  syphilis 
in  the  army,  he  stresses  the  large  number  of  venereal  cases 
in  men  mobilized  for  munition-work.  Medical  inspections 
ought,  according  to  Thibierge,  imperatively  to  be  made  in 
the  munition-works  and  upon  all  mobilized  workmen,  whether 
French  or  belonging  to  the  Colonial  contingents.  These  men 
are  under  military  control  in  France,  but  they  have  more 
opportunities  than  the  soldiers  for  contracting  and  dissemi- 
nating syphilis.  They  are,  in  point  of  fact,  very  often  in- 
fected and  in  a  higher  proportion  than  are  the  soldiers  at 
the  front.  The  munition-workers  should  also  be  obliged  to 
report  their  infections  to  the  physician,  whether  or  no  they 
are  under  treatment  by  military  or  by  private  physicians. 

Thibierge  devotes  a  chapter  to  syphilis  as  a  national  danger. 
Not  only  do  available  statistics  prove  that  there  is  more 
syphilis  in  the  population  since  the  outbreak  of  war,  but 
the  number  of  married  women  going  to  special  hospitals  for 
syphilis  is  abnormally  high  and  entirely  out  of  proportion 
to  the  number  of  married  women  resorting  to  these  clinics  in 
peace  times.  A  certain  number  are  contaminated  by  their 
husbands  on  leave.  Thibierge  calls  attention  to  the  fact  of 
the  extraordinary  frequency  of  syphilis  in  young  men  (two 
or  three,  sixteen  to  eighteen  years  of  age,  at  Saint-Louis 
Hospital  at  each  consultation). 


SYPHILOPSYCHOSES  1 7 


A  disciplinary  case:  Syphilitic? 


Case  II.     (Kastan,  January,  1916.) 

Reports  varied  about  a  certain  German  soldier  who  came 
up  for  discipline.  Inferiors  thought  he  was  harsh  and  tricky. 
A  lieutenant  declared  that  the  man  always  wanted  to  have 
proper  respect  paid  to  him,  and  that  he  was  unduly  excited 
by  trifles.  The  man  had  become  latterly  very  nervous  on 
account  of  battle  strain  and  protracted  shelling. 

July  28,  1 91 5,  the  man,  who  had  been  drinking  with  com- 
rades the  night  before,  was  excitedly  talking  to  an  officer  con- 
cerning relief  of  a  guard.  The  soldier  stated,  "As  a  sergeant 
on  duty  with  a  service  record  of  1 5  years,  I  think  it  Is  my  affair." 
The  heutenant  replied,  "So  far  as  I  am  concerned,  the  matter 
is  settled."  The  sergeant  yelled,  "As  far  as  I  am  concerned, 
it  is  settled  also.  By  the  way,  my  name  Is  Mr.  Vice  Ser- 
geant .  .  .  ,"  and  with  that  the  sergeant  wrote  down  the 
Heutenant's  words  and  refused  to  obey  the  lieutenant's  order 
to  "Stop  writing."  The  lieutenant  drew  his  sword  and  said, 
"Take  your  hands  down."  The  sergeant  replied,  "Surely 
I  am  permitted  to  write."  Lieutenant:  "Subordination; 
don't  forget  yourself.  Vice  Sergeant  ...  ."  The  sergeant 
jeered,  "You  forgot  yourself  anyhow;"  whereupon  the  lieu- 
tenant: "Well,  such  a  thing  never  happened  to  me  before." 
The  sergeant,  jeeringly,  "Nor  to  me  either.  If  I  were  not  In 
undress  I  should  know  what  to  do."  The  Heutenant:  "Vice 
Sergeant  .  .  .  ,  remain  here.  This  matter  will  be  settled  at 
once."  The  sergeant:  "It  is  Mr.  Vice  Sergeant  .  .  .  ," 
whereupon  he  gave  his  notebook  to  a  hornblower  and  said, 
"Write."  The  lieutenant:  "Stay."  Thesergeant:  "What, 
stay  here.  No,  I'll  not  stay,"  and  made  off.  The  lieutenant 
called  after  him,  "Put  on  your  service  dress  and  see  the 
captain."  He  made  ready  but  said,  "This  half-Idiot  gives 
an  order  Hke  that  to  a  sergeant  with  15  years'  record." 

The  examination  showed  that  the  man  had  a  hypalgesla. 
He  complained  of  violent  headaches.  He  said  that  he  had 
had  syphilis  10  years  before;  there  were  no  bodily  stigmata. 


1 8  SYPHILOPSYCHOSES 


Regulations  broken :   General  paresis. 


Case  12.     (Kastan,  January,  1916.) 

A  German  ist-lieutenant,  on  active  service  before  the  war, 
had  left  the  service  because  there  was  not  enough  for  him  to 
do  in  peace  times.  During  his  war  serv'Ice,  he  became  drunk 
and  had  two  soldiers  bound  to  a  doorpost,  with  coats  un- 
buttoned and  without  their  caps  —  a  process  quite  verboten. 
While  in  Konigsberg,  he  reported  himself  ill,  and  failed  to 
go  to  a  designated  hospital.  He  was  accordingly  treated 
as  a  deserter.  He  ran  up  bills  with  landlady  and  servant 
girls,  saying  that  he  was  going  to  receive  money  from  his 
wife.  Under  hospital  examination,  he  said  he  was  only  a 
Baden  man  with  a  lively  temperament.  He  got  angry  at 
the  phrase  test  feeding,  refused  food,  got  excited  when  asked 
to  help  in  the  care  of  other  patients,  and  wrote  a  letter  saying, 
"If  it  is  the  idea  to  make  me  nervous  by  removing  the  air 
from  me,  by  prescribing  rest  in  bed  —  a  punishment  only 
suitable  for  a  boy  who  cannot  keep  himself  neat  —  and  such 
chicaneries,  these  philanthropic  attempts  are  bound  to  fail 
on  my  robust  peasant  nerves.  Of  course  I  know  that  money 
considerations  make  the  stay  of  every  paying  patient  desir- 
able, but  I  am  really  too  good  for  that.  [The  expenses  were 
being  borne  by  the  state.]  I  have  openly  stated  what  Is  being 
here  done  with  me  is  foolery,  and  I  stick  to  that  phrase.  The 
food,  already  poor  enough,  is  no  better,  when  the  meat  of  a 
half -rotten  cow  comes  t\vice  to  the  table."  This  patient  was, 
according  to  Kastan,  a  victim  of  general  paresis. 

Re  general  paresis  and  delinquency,  Gilles  de  la  Tourette 
long  ago  maintained  that  there  was  a  medicolegal  period  in 
paresis.  Leplne  In  his  work  on  Troubles  Mentales  de  la 
Guerre  speaks  of  the  unexpected  frequency  of  general  paresis 
in  the  army,  and  calls  attention  at  the  outset  to  the  medico- 
legal period.  The  danger  of  overt  delinquency  is,  in  fact, 
greater  under  military  than  under  civilian  conditions  on  ac- 
count of  the  closer  surveillance  of  the  soldier.  Desertion 
and  thievery  are  the  main  forms. 


SYPHILOPSYCHOSES  1 9 

Unfit  for  service :     General  paresis. 


Case  13.     (Kastan,  January,  1916.) 

Kastan  describes  a  non-commissioned  officer,  who  came 
voluntarily  into  the  clinic.  It  seems  that  he  had  absented 
himself  (?)  from  the  army  in  the  suburbs  of  Konigsberg, 
September  3,  1914.  He  was  arrested  October  7th.  Once 
before  he  had  been  brought  to  Kastan's  clinic  on  the  suspicion 
of  general  paresis,  but  had  been  dismissed  as  non-paretic. 
Brought  in  again  In  a  condition  of  marked  fear,  he  declared 
that  he  had  to  fall  behind  his  company  while  he  was  on  the 
march  on  account  of  a  feeling  of  weakness.  He  had  been 
taken  to  a  hospital  and  then  carried  to  the  suburbs  of  Konigs- 
berg, examined,  and  found  unfit  for  service. 

He  had  in  his  20th  year  become  infected  with  syphilis,  and 
had  recently  become  forgetful,  subject  to  fears,  and  easily 
excitable.  He  had  been  very  unhappily  married  with  a 
woman  who  was  hysterical  and  threatened  to  shoot  and 
poison  him.  He  lived  in  a  condition  of  continual  quarrels 
with  her.  The  symptoms  that  he  felt  on  the  march  were 
numbness  of  the  legs  and  a  rush  of  blood  to  the  head.  In 
the  clinic,  he  was  subject  to  much  dreaming  and  raving  about 
the  war.     There  was  excessive  perspiration. 

I.  As  to  the  proper  interpretation  of  this  case,  details  are 
lacking  as  to  the  physical  and  laboratory  side.  In  fact, 
it  would  appear  that  the  suspicion  of  paresis  at  his  first 
reception  In  a  clinic  was  dismissed  without  resort  to 
laboratory  findings. 

There  are  no  neurological  symptoms  In  the  case 
clearly  suggestive  of  neurosyphilis,  except  perhaps  the 
numbness  of  the  legs.  The  remainder  of  the  picture 
appears  to  be  entirely  psychic.  Sensory  and  intellec- 
tual symptoms  are  missing  unless  we  count  the  war 
dreams  and  mania  as  Intellectual.  It  appears  wiser 
to  count  these  as  emotional  In  the  sense  that  they  were 
roused  by  emotion-laden  memories.  The  fear,  per- 
spiration, and  feelings  of  head  flush  are  perhaps  to  be 
best  Interpreted  as  satellites  about  an  emotional  nucleus. 


20  SYPHILOPSYCHOSES 


Hysterical  chorea  versus  neurosyphilis. 


Case  14.     (De  Massary  and  Du  Sonich,  April,  1917.) 

There  were  various  complications  in  the  case  of  a  lieutenant 
(nervous  tic  in  childhood ;  travel  23  to  30) ,  who  was  at  Ant- 
werp during  the  period  of  mobilization.  He  was  taken  there 
by  the  Germans;  was  a  prisoner  in  their  hands  for  55  days; 
and  succeeded  under  great  strain  in  escaping. 

He  then  entered  his  regiment,  and,  passing  the  examina- 
tions, was  made  an  adjutant,  and  went  to  the  front,  March, 
191 5.  He  stayed  ten  months  in  the  Verdun  region,  under 
heavy  bombardment,  and  in  June  was  bowled  over  and  buried 
by  a  210.  He  seemed  to  be  fearless,  getting  no  sensation 
from  shell-bursts  except  a  griping  sensation  in  the  bowels. 

However,  his  character  had  altered  in  the  direction  of 
irritability;  and  by  the  end  of  January,  19 16,  he  had  to  be 
evacuated  for  the  first  time  from  the  front,  for  general  weak- 
ness, with  the  diagnoses:  neurasthenia,  neuralgia,  dyspeptic 
troubles,  great  general  fatigue,  marked  depression.  In  fact, 
at  Narbonne  he  was  asked  no  questions  for  several  days  on 
account  of  his  obvious  depression.  He  was  given  ice-bags 
for  violent  headaches,  complete  rest  in  bed,  cacodylate  and 
sodium  nucleinate.     In  two  weeks  he  was  up  and  about. 

At  this  time  appeared  choreiform  movements,  which 
reached  their  maximum  in  two  or  three  days,  whereupon  he 
was  sent,  March  4,  1916,  to  the  neurological  centre  at  Mont- 
pellier.  Here  W.  R.  positive!  Neosalvarsan  on  the  second 
injection  (0.45  and  0.60)  yielded  a  strong  reaction,  with  fever, 
deUrium,  vomiting,  and  then  jaundice. 

About  a  month  later,  he  was  given  twenty  more  intra- 
venous injections,  whereupon  the  choreic  movements  now 
decreased,  and  July  15  he  was  given  convalescence  for  three 
months.  October  15  he  went  back  to  his  depot  cured;  and 
October  20,  on  request,  went  to  the  front.  He  was  potted 
and  under  machine-gun  fire  at  times  during  the  next  three 
months,  but  the  choreic  movements  did  not  reappear.  Janu- 
ary I  he  left  the  trenches  as  the  division  went  into  billets. 


SYPHILOPSYCHOSES  21 

January  8,  suddenly,  without  any  emotional  cause,  he  began 
to  "dance"  again.  Accordingly,  he  was  evacuated  for  the 
second  time,  January  lo,  1917,  with  the  diagnosis:  choreic 
movements,  especially  on  left;  evacuate  to  special  centre. 

At  Royallieu,  a  lumbar  puncture  showed  a  slight  lympho- 
cytosis. The  headache  improved.  He  was  evacuated  Janu- 
ary 24,  1917,  to  Val-de-Grace,  with  a  diagnosis:  Recurrent 
chorea;  first  attack  followed  commotio  cerebri,  nervous  de- 
pression, inequality  of  pupils,  various  pains,  contracted  in 
the  army.  Another  W.  R.  was  positive.  Twelve  intra- 
muscular injections  of  oxygen  cyanide  were  given,  besides 
baths.  He  was  then  sent  to  Issy-les-Moulineaux  with  a 
diagnosis  of  tic.  He  showed  choreiform  movements  affecting 
the  legs  alone.  When  sitting,  legs  extended  and  flexed,  the 
knees  would  abduct,  then  adduct;  the  thighs  flexed.  When 
standing,  flexor  movements  were  produced  alternately  on  the 
left  and  the  right,  the  knee  being  raised  high,  sometimes 
striking  the  patient's  hand.  In  walking,  the  thigh  and  lower 
leg  flexion  was  always  out  of  proportion  to  the  required  step. 
There  was  thus  a  sort  of  saltatory  chorea  limited  to  the  legs. 
The  reflexes  so  far  as  they  could  be  tested  were  normal  save 
that  the  left  pupil  was  fixed  to  light  and  accommodation;  the 
right  pupil  was  sluggish  to  light  but  accommodated  normally, 
Leucoplakia  of  the  cheeks;  nocturnal  headaches;  and  pains 
resembling  lightning  pains  in  arms  and  legs.  Lumbar  punc- 
ture, March  26,  showed  blood-stained  fluid,  and  the  puncture 
was  followed  by  headache,  vomiting,  and  slow  pulse.  The 
fluid  showed  a  slight  lymphocytosis;  W.  R.  negative. 

It  is  clear  that  a  diagnosis  limiting  itself  to  the  leg  trouble 
would  probably  content  itself  with  "hysterical  chorea.'*  The 
lieutenant  said  that  when  he  saw  people  "dance  "  he  did  have 
a  tendency  to  imitate  them ;  and  when  he  was  cured  of  that, 
he  did  not  want  to  go  to  Lamalou  because  he  would  see  the 
ataxic  patients  there  and  might  fall  back  into  his  "dancing." 
However,  in  view  of  the  pupillary  inequality,  the  lympho- 
cytosis, the  leucoplakia,  the  W.  R.,  and  the  initial  neuras- 
thenia and  depression  found  in  the  very  first  hospital  in  which 
he  was  examined,  we  probably  should  be  entitled  to  consider 
that  general  paresis  played  a  part  in  the  chorea. 


22  SYPHILOPSYCHOSES 


Shrapnel  fragment  driven  through  skull:  General 
paresis. 


Case  15.     (Hurst,  April,  191 7.) 

A  private,  31,  was  wounded  December  7,  1916,  by  a  shrap- 
nel fragment  which  entered  the  skull  above  the  left  ear  and 
lodged  in  the  brain,  an  inch  above  and  2|  inches  below  the 
middle  of  the  right  orbital  margin.  At  Netley,  December  30, 
he  proved  to  show  a  complete  internal  and  external  left  sided 
ophthalmoplegia,  with  the  exception  of  the  external  rectus. 
On  the  right  side,  there  was  a  complete  paralysis  of  the  superior 
rectus  and  a  partial  paralysis  of  the  inferior  rectus  and  levator 
palpebrae  superioris.  There  was  a  paresis  of  the  left  side  of  the 
face.  The  right  plantar  reflex  was  said  to  have  been  extensor 
at  the  clearing  station,  but  at  Netley  it  and  the  other  reflexes 
proved  to  be  normal,  as  were  the  optic.  The  patient  was 
stuporous  and  had  incontinence  of  urine  and  feces  for  two 
days.  Shortly  after  admission,  slurring  of  speech  with  a  long 
latent  period  occurred.  It  was  clear  that  the  shrapnel  frag- 
ment must  have  passed  far  above  the  crus,  and  it  was  not 
plain  how  isolated  lesions  of  the  third  and  seventh  nerve 
nuclei  could  have  been  brought  about  without  injury  of  the 
long  tracts  of  the  crus. 

The  Wassermann  reaction  of  the  serum  was  negative,  but 
that  of  the  spinal  fluid  was  positive.  Iodide  and  mercury 
secured  considerable  improvement  in  the  mental  condition 
and  some  diminution  in  the  paralysis.  The  patient  is  now 
extremely  pleased  with  himself  and  has  a  speech  suggestive 
of  paresis. 


SYPHILOPSYCHOSES  23 

Head  trauma:  Shell-shock  effects,  over  in  a  few 
months.  Manic-depressive  (?)  attack  more  than 
two  years  later.  X-ray  evidence  suggesting  brain 
lesion.     Serum  Wassermann  reaction  positive. 


Case  i6.     (Babonneix  and  David,  June,  191 7.) 

A  bullet  glancing  from  his  gun  barrel  November  28,  19 14, 
wounded  a  man  in  the  head,  whereupon  he  lost  consciousness 
and  was  carried  to  a  hospital  and  trephined.  On  coming  to, 
he  found  that  he  could  not  hear  and  felt  pains ;  but  the  latter 
disappeared  in  a  few  months.  He  was  given  sedentary 
employment  and  did  his  work  properly  until  February,  191 7, 
when  he  suddenly  became  sad,  wept,  slept  poorly,  stopped 
eating,  had  an  absent  air,  and  began  to  complain  of  his  head. 
He  passed  whole  days  without  moving,  in  a  sort  of  stupor, 
which  was  then  followed  by  a  hypomaniacal  agitation  in 
which  he  walked  furiously  up  and  down  in  the  room  and  threw 
objects  about. 

He  was  found  subject  to  a  generalized  tremor  and  he  was 
distinctly  weaker  on  the  right  side.  The  tendon  reflexes 
were  excessive.  The  bony  sensibility,  as  well  as  the  pain  and 
temperature  sense,  and  the  position  and  stereognostic  senses 
were  completely  abolished  on  the  right  side.  The  scar  lay 
on  the  left  side.  It  was  deep  and  very  sensitive  to  pressure, 
so  that  if  it  was  touched  ever  so  slightly  the  patient  began  to 
weep.  X-ray  indicated  loss  of  substance  in  the  posterior  part 
of  the  left  parietal  region.  Remains  of  the  projectile  were 
found  subcutaneously  in  the  right  supraorbital  region.  The 
W.  R.  of  the  serum  was  positive.  There  was  no  lympho- 
cytosis in  the  spinal  fluid. 

Interpretation  of  this  case  is  manifestly  difficult.  Four 
possibilities  exist:  Syphilis,  manic  depressive  psychosis,  trau- 
matic brain  disease,  and  functional  shock  effects.  More 
than  two  years  had  passed  between  the  trauma  and  the 
change  of  character. 


24  SYPHILOPSYCHOSES 

Skull  trauma  in  a  syphilitic. 


Case  17.     (Babonneix  and  David,  June,  191 7.) 

A  soldier,  31,  sustained  fracture  of  the  occiput  from  shell- 
burst,  and  thereafter  showed  confusion  and  total  loss  of 
memory.  Operation  November  1 1  withdrew  bony  fragments 
and  clots,  whereupon  the  man  returned  practically  to  normal. 
He  developed,  however,  a  few  seizures,  in  which  he  struggled, 
fell,  and  lost  consciousness,  afterward  suffering  from  head- 
ache. The  tendon  reflexes  were  increased.  The  occipital 
cicatrix  was  a  little  depressed  and  slightly  painful  on  pressure. 

Lumbar  puncture  showed  a  very  slight  lymphocytosis  (5 
to  6  cells),  practically  negative  globulin  reaction,  and  a  low 
albumin  titer.  There  were  no  signs  of  syphilis  in  the  eyes. 
The  W.  R.  in  the  serum  was  strongly  positive.  Very  possibly 
the  traumatic  phenomena  in  this  case  can  be  safely  disengaged 
from  the  syphilitic  phenomena. 

Re  the  mechanism  by  which  trauma  evokes  or  accelerates 
the  course  of  neurosyphilis,  it  is  probable  that  most  neuro- 
pathologists believe  that  the  commotio  cerebri  causes  sundry 
chemical  or  physical  effects  in  the  nerve  tissues  such  that 
spirochetes  are  moved  into  new  and  more  dangerous  places, 
or  such  that  more  appropriate  food  is  supplied  to  the  organ- 
isms, which  then  begin  to  multiply.  Whether  the  organisms 
live  in  a  kind  of  symbiosis  in  the  tissues  under  ordinary  cir- 
cumstances in  the  pre-paretic  period  of  the  development  of 
neurosyphilis,  is  unknown.  Possibly  fat  embolism  should 
be  added  to  the  list  of  possible  causes  of  the  hastening  of 
the  neurosyphilitic  process.  Fat  embolism  in  the  brain  has 
been  shown  by  various  authors  to  be  accompanied  by  minute 
hemorrhages,  in  the  midst  of  which  by  proper  stains  the 
fat  embolism  can  be  made  out. 


SYPHILOPSYCHOSES  2$ 

Shell-wound  in  battle :   General  paresis. 


Case  i8.     (Boucherot,  191 5.) 

A  soldier  in  the  Territorial  Infantry,  42,  a  gardener  who  went 
to  taverns,  as  he  said,  "like  everybody  else,"  a  widower  with 
two  children,  a  good  worker  though  irascible,  had  had  syphilis 
as  a  youth.  He  was  called  to  the  colors  at  the  outbreak  of  the 
war  and  got  on  well  despite  tremendous  strain.  March  9, 
1915,  he  was  in  a  bayonet  charge  with  his  regiment  and  was 
bowled  over  by  a  shell  of  which  a  fragment  wounded  him 
above  the  knee  and  several  fragments  in  the  thorax.  All 
these  fragments  were  extracted  at  a  temporary  hospital, 
March  11.  The  man  now  became  strange,  refused  to  obey 
orders  and  did  a  number  of  peculiar  things  so  that  he  was 
sent  to  Orleans  temporary  hospital  whence  he  was  evacuated 
to  Fleury  Asylum,  March  19,  He  refused  to  give  up  his 
things  because  he  was  the  master.  He  did  not  want  to  go  to 
bed  and  wanted  to  keep  on  walking  constantly.  He  was 
without  sense  of  shame,  satisfied  with  himself,  grandiose  as 
to  his  millions  in  bank  and  the  thirty-six  decorations  he 
believed  had  been  awarded  him.  He  mistook  the  identity  of 
the  landscape  and  of  the  people  about  him. 

Tongue  tremulous ;  pupils  unequal ;  knee-jerks  exaggerated; 
dysarthria;  gaps  in  memory.  In  May  occurred  a  number 
of  violent  reactions. 

In  June,  however,  there  was  a  remission;  the  ideas  of 
grandeur  disappeared  first,  then  the  tremors  and  reflex  dis- 
order and  finally  the  speech  disorder.  There  was  a  slight 
seizure  at  this  point  and  the  man  said  he  had  had  another 
such  just  before  he  came  to  the  army.  July  20  he  was  in- 
valided out  much  improved. 

In  this  case  of  general  paresis  there  is,  besides  the  syphilis, 
also  alcoholism  to  consider,  so  that  it  is  not  entirely  plain 
that  the  exertions  of  campaign  liberated  the  paresis. 

Re  wounds  and  paresis,  see  also  Case  5  (Beaton),  in  which 
neurosyphilis  advanced  rapidly  from  the  time  of  a  trivial 
injury. 


26  SYPHILOPSYCHOSES 


Shell-explosion :    Syphilitic  ocular  palsy. 


Case  19.  (Schuster,  November,  191 5.) 
Schuster  notes  briefly  a  curious  result  of  the  explosion  of  a 
shell,  which  caused  the  patient  in  question  to  lose  conscious- 
ness. Shortly  after  the  explosion,  the  patient  came  to  his 
senses  again,  but  a  surprising  paresis  of  the  eye  muscles  had 
developed.  This  paresis  looked  precisely  like  a  syphilitic 
paresis  clinically. 

Examination  of  the  blood  serum  yielded  a  strongly  positive 
Wassermann  reaction. 

According  to  Schuster,  the  explosion  of  the  shell  had 
brought  about  hemorrhage  in  vessels  supplying  the  region 
of  the  eye  muscle  nerves  or  nuclei.  The  reason  for  the  selec- 
tion of  these  vessels  for  rupture  due  to  shell  explosion  is, 
according  to  Schuster,  that  the  vessels  were  probably  already 
syphilitically  diseased. 

Re  hemorrhages  in  the  neighborhood  of  the  oculomotor 
nuclei,  the  phenomena  of  polioencephalitis  may  be  recalled. 
In  that  disease,  the  predisposition  to  hemorrhage  is  presumed 
to  be  alcoholic,  as  the  cases  of  ophthalmoplegia  of  this  group 
almost  always  appear  in  alcoholics.  However,  the  first  case 
of  hemorrhagic  superior  polioencephalitis  was  a  non-alcoholic 
one  of  Gayet  (1875),  in  which  the  symptoms  followed  three 
days  after  a  boiler  explosion. 


SYPHILOPSYCHOSES  27 

A  tabetic  lieutenant  "  shell-shocked  "  into  paresis? 


Case  20.     (DoNATH,  July,  1915.) 

An  apparently  competent  German  professor  in  an  inter- 
mediate school,  a  lieutenant  of  infantry  reserves,  33  years 
old,  on  the  17th  August,  1914,  was  stunned  for  a  while  by 
the  shock  of  a  cannon-firing  25  feet  away.  Urination  became 
difficult.  Headaches  and  limb  pains  ensued,  with  paralysis 
of  fingers,  gastric  troubles,  forgetfulness,  especially  for  names, 
insomnia,  and  general  scattering  of  mental  faculties. 

Neurologically,  the  pupils  were  irregular,  left  larger  than 
right;  Argyll- Robertson  reaction.  Right  knee-jerk  livelier 
than  left.  Achilles  reactions  absent.  Slow  and  dissociated 
pain  reactions  in  feet,  lower  thighs  and  lower  quarter  of  upper 
thighs,  with  hypalgesia  or  analgesia.  Station  good;  gait 
steady.  Mentally  depressed,  slow  of  thought.  Speech  poor 
and  of  indistinct  construction  (mild  dementia).  Calculation 
ability  poor.     No  pleasure  in  work. 

Wassermann  reaction  of  serum  weakly  positive. 

It  seems  that  for  a  year  the  patient  had  been  subject  to 
spells  of  anger.  He  was  irritated  by  his  wife  who  had  been 
nervous  since  an  earthquake. 

On  the  occasion  of  the  earthquake,  191 1,  the  patient  himself 
had  had  a  spell  of  difficulty  with  urination.  The  spell  had 
lasted  two  or  three  months.  The  patient  had  had  a  chancre 
in  1902,  "cured  "  in  four  or  five  weeks  with  xeroform.  In 
1908,  when  about  to  marry,  he  had  had  six  mercurial  inunc- 
tions. 

Re  tabes,  Lepine  shows  that  tabetics  are  numerous.  They 
are  numerous  among  officers  and  also  in  the  auxiliary  service, 
in  which  latter  tabetics  are  maintained  on  desk  duty.  Per- 
haps they  had  been  admitted  to  such  work  as  unable  to 
march  or  fight,  on  the  basis  of  having  had  so-called  "rheu- 
matism." 


28  SYPHILOPSYCHOSES 


Shell-explosion  may  precipitate  neurosyphilis  in  the 
form  of  tabes  dorsalis. 


Case  21.     (LoGRE,  March,  191 7.) 

An  artilleryman,  38,  had  a  large  calibre  shell  explode  very 
near  him  and  afterward  could  not  hear  the  whistle  of  a  shell 
without  falling  down  in  a  generahzed  tremor,  sweating  pro- 
fusely, urinating  Involuntarily,  In  a  mental  state  approaching 
stupidity.  Here  was  a  case  that  might  be  regarded  as  one 
of  morbid  cowardice  in  a  psychopath,  following  violent 
emotion. 

The  artilleryman  proved  to  be  a  victim  of  tabes  and  of 
general  paresis.  The  incontinence  of  urine  under  the  in- 
fluence of  emotion  was  nothing  but  an  effect  of  tabetic 
sphincter  disorder.  The  crisis  of  cowardice  proved  nothing 
but  an  initial  symptom  of  general  paresis. 


Shell-explosion ;  burial :  Tabes  dorsalis  incipiens. 


Case  22.     (Duco  and  Blum,  1917.) 

A  French  soldier  was  burled  by  effects  of  shell  explosion 
September  8,  1914.     He  sustained  no  wound  or  fracture. 

Incontinence  of  urine  developed.  Anesthesia  of  penis  and 
scrotum.  Reflexes  absent;  pupils  sluggish.  Wassermann 
reactions  suspicious. 

The  diagnosis  tabes  dorsalis  incipiens  was  made  (hema- 
tomyella  of  conus  termlnalls  eliminated) . 

The  patient  was  estimated  to  be  "40%  incapacitated," 
according  to  the  French  ''  echelle  de  gravite  "  of  conditions.  A 
full  pension  would  not  be  justified  in  the  opinion  of  the 
French  authors. 


SYPHILOPSYCHOSES  29 

SHELL-SHOCK  PSEUDOTABES   (non-syphilitic, 
serum  W.  R.  positive) .    Improvement. 


Case  23.     (PiTRES  and  Marchand,  November,  191 6.) 

Innkeeper  B.,  36,  a  shell-shock  and  burial  victim  June  20, 
IQIS)  was  looked  on  by  a  number  of  physicians  as  a  case  of 
genuine  tabes. 

Even  eight  months  after  the  episode,  he  still  showed  (when 
observed  by  Pitres  and  Marchand,  February  3,  191 6) 
absence  of  knee-jerks  and  Achilles  jerks,  a  slight  swaying  in 
the  Romberg  position,  pupils  sluggish  to  light,  incoordination, 
delayed  sensations.  There  was  also  a  history  of  pains  in  the 
legs,  compared  by  the  patient  to  those  of  sciatica.  These 
pains  came  in  crises,  the  longest  of  which  had  lasted  30  hours. 

It  seems  that  this  soldier's  troubles  began  the  day  after  his 
shock  with  a  feeling  of  swollen  feet  and  of  cotton  wool  under 
them.  He  stayed  on  service,  however,  walking  with  increas- 
ing difficulty. 

At  the  time  of  his  evacuation,  July  10,  he  could  walk  with 
great  difficulty.  "Strips  of  lead  were  between  his  legs."  He 
could  hardly  control  movements  in  the  dark,  or  descend 
stairs.  Often  his  legs  would  bend  under  him.  Vesical  func- 
tion sluggish. 

After  a  few  months  the  patient  could  walk  better.  In 
February,  191 6,  he  walked  thrusting  his  legs  forw^ard  trem- 
bling, and  dragging  toes  a  little.  He  could  not  support  himself 
on  either  leg.  Jerkiness  and  incoordination  in  extension  or 
flexion  of  leg  on  thigh. 

The  muscular  weakness  was  decidedly  against  tabes  or  at 
all  events  a  pure  tabes.  The  incoordination  proved  to  be  due, 
not  to  loss  of  position  sense  (which  was  intact)  but  to  un- 
steady muscular  contractions.     Deep  sensibility  was  intact. 

There  were  no  mental  symptoms.  There  was  a  slight 
hesitation  in  speech  and  doubling  of  syllables,  but  nothing 
demonstrable  with  test  phrases. 

The  serum  W.  R.  was  positive. 


30  SYPHILOPSYCHOSES 

Shell  explosion;    unconsciousness:    Neurosyphilis. 


Case  24.     (Hurst,  April,  1917.) 

A  private,  31,  was  in  the  retreat  from  Mons,  was  blown  up 
by  a  shell  and  buried  in  May,  191 5,  went  back  to  the  front 
after  two  months  leave,  was  knocked  unconscious  by  a  shell 
December,  19 16,  He  came  to  himself  two  days  later  in  the 
hospital,  but  remained  confused  and  lethargic.  In  England, 
December  21,  his  legs  were  still  weak  and  walking  was 
unsteady.  The  right  pupil  reacted  neither  to  light  nor  to 
accommodation  and  was  irregular,  eccentric,  and  dilated. 
The  left  pupil  showed  the  Argyll-Robertson  reaction.  There 
was  early  primary  optic  atrophy.  The  right  knee-jerk  was 
slightly  exaggerated.  The  vibration  sense  was  reduced  over 
sacrum  and  malleoli.  At  this  time  the  man's  mental  condi- 
tion was  practically  normal. 

The  Wassermann  reaction  of  the  serum  and  spinal  fluid 
proved  positive.  Improvement  followed  rest,  iodide,  mer- 
cury, and  seven  injections  of  salvarsan.  By  the  middle  of 
February  he  was  able  to  walk  well.  The  right  pupil  regained 
its  power  to  react  to  accommodation,  but  remained  inactive 
to  light.  Meanwhile,  the  left  pupil  had  regained  a  slight 
power  to  react  to  light. 

Re  treatment  of  syphilis,  both  Thibierge  and  Lepine  give 
warning  of  some  bad  results  with  arsenobenzol  treatment, 
though  Thibierge  states  that  the  number  of  serious  accidents 
and  especially  of  deaths  has  diminished  more  and  more 
now  that  no  arsenobenzol  (drug  No.  914)  is  given.  En- 
cephalitis is  the  gravest  of  the  untoward  results  of  injection, 
sometimes  appearing  in  young  and  vigorous  subjects.  Hem- 
orrhagic encephalitis  appears  to  occur  more  frequently  after 
the  second  injection  than  after  the  first,  and  according  to 
Thibierge  may  be  especially  suspected  in  subjects  who  after 
the  first  injection  present  much  fever,  congestion  of  face, 
and  cutaneous  eruptions.  Treatment  in  these  cases  should 
be  suspended  or  given  in  moderate  doses. 


SYPHILOPSYCHOSES  3 1 

Shell-explosion:  Neurosyphilis.    Fit  for  light  duty. 


Case  25.     (Hurst,  April,  191 7.) 

A  corporal,  26,  blown  up  by  a  shell  December  7,  1916,  was 
admitted  to  the  hospital  on  the  13th,  dazed  and  with  symp- 
toms of  a  left-sided  hemiplegia  of  organic  origin.  The  right 
pupil  was  larger  than  the  left.  There  was  a  bruise  of  the 
scalp  in  the  right  parietal  region.  The  man  had  had  syphilis 
at  16.  The  Wassermann  reaction  of  the  serum  was  strongly 
positive.  Rest,  salvarsan,  mercury,  and  iodides  were  given, 
and  the  general  symptoms  and  hemiplegia  gradually  dis- 
appeared, until  on  December  12  there  was  only  a  moderate 
weakness  of  the  left  side,  with  knee-jerks  in  excess,  abdominal 
reflexes  absent,  and  the  Babinski  reaction. 

The  Wassermann  reaction  was  still  strongly  positive. 
Salvarsan,  mercury,  and  iodide  were  continued.  January  6, 
1917,  the  plantar  reflex  had  become  flexor.  The  abdominal 
reflex  returned.  Babinski's  second  sign  (combined  flexion  of 
thigh  and  pelvis)  was  now  the  only  evidence  of  organic 
disease.  Further  antisyphllltic  treatment  removed  this  sign 
also.  February  28,  the  man  was  discharged  fit  for  light  duty, 
with  unequal  pupils  and  positive  Wassermann  reaction,  and 
a  complete  amnesia  for  the  four  weeks  following  his  blowing 
up  In  the  trenches. 

Re  fitness  for  light  duty,  see  remarks  on  Case  20  concerning 
desk  duty  for  certain  tabetics. 

Re  the  premature  or  unexpectedly  early  appearance  of 
neurosyphilis  under  war  conditions,  the  early  claims  of  some 
authors  have  not  been  maintained.  In  the  above  Instance, 
the  infection  was  at  16  and  the  shell  explosion  occurred  at 
26,  namely,  at  about  the  right  interval  for  the  development 
of  neurosyphllltic  signs.  Gerver  states  that  military  service 
brings  out  the  lesions  of  paresis  earlier  than  they  would 
otherwise  come.  Bonhoeffer  has  been  unable  to  show  that 
cerebrospinal  syphilis  is  favored  in  its  development  by  the 
exhaustion  factor. 


32  SYPHILOPSYCHOSES 


SHELL-SHOCK    PSEUDOPARESIS    (non-syphi- 
litic).    Recovery. 


Case  26.     (PiTRES  and  Marchand,  November,  191 6.) 

June  19,  191 5,  a  shell  exploded  some  distance  from  Lieuten- 
ant R.  He  remembers  the  gaseous  smell,  the  bursting  of 
several  shells  nearby  and  a  sensation  of  being  lifted  into  the 
air.  When  he  recovered  consciousness,  he  was  in  hospital 
at  Paris- Plage,  covered  with  bruises  and  scratches.  They 
told  him  he  had  been  delirious  and  had  vomited  and  spat 
blood. 

June  24,  his  wife  came  to  see  him,  but  this  visit  he  could 
not  remember.  Nor  could  his  wife  at  first  recognize  him,  he 
was  so  thin.  He  roused  a  few  moments  and  recognized  his 
wife,  but  relapsed  into  torpor  again.  Speech  was  difficult 
and  ideas  confused. 

A  few  days  later  he  was  able  to  rise;  but  his  mental  status 
grew  worse,  especially  as  to  speech  and  writing,  the  latter 
quite  illegible.     There  was  insomnia,  or,  if  he  slept,  war  dreams. 

August  7,  he  began  a  period  of  five  months'  convalescence 
passed  with  his  family,  depressed,  given  to  spells  of  weeping, 
confined  to  bed  or  couch,  unable  to  "find  words,"  conscious 
of  his  state  and  troubled  about  it,  speaking  of  nothing  but 
the  war,  and  afraid  to  go  out  for  fear  of  ambuscade.  There 
was  at  first  a  slight  lameness  of  the  right  leg.  Although  he 
could  walk,  he  felt  pain  in  the  knee  on  flexing  the  right  leg 
on  the  thigh.     He  walked  holding  this  leg  in  extension. 

On  going  back  to  the  colors,  he  was  immediately  evacuated 
to  the  Centre  Neurologique  at  Bordeaux,  January  20,  191 6. 

Examination  found  a  bored,  impatient,  irritated  man,  vexed 
that  a  man  who  was  not  sick  should  be  sent  up  "comniefou" 

Omitting  negative  details,  neurological  examination  showed 
slight  lameness  as  above,  body  stiff  and  movements  jerky, 
difficult,  unsteady  gait.  The  lieutenant  could  stand  for  some 
time  on  either  leg.  Tongue  and  face  tremulous  during  speech. 
Limbs  moderately  tremulous,  especially  in  the  performance 
of  test  movements. 


SYPHILOPSYCHOSES  33 

Knee-jerks  and  Achilles  jerks  absent.  Other  reflexes,  in- 
cluding pupillary,  normal.  Segmentary  hypalgesia  of  right 
leg,  especially  about  knee.  Tremulous  speech  and  writing. 
Patient  would  stop  short  in  speaking  for  lack  of  words. 

Malnutrition.  Appetite  good,  but  a  bursting  feeling  after 
meals. 

Skin  dry,  scaly  on  legs,  fissured  on  fingers. 

Serum  W.  R.  negative.     Fluid  not  examined. 

Mental  examination.  Conscious  and  complaining  of  his 
troubles.  Lieutenant  R.  claimed  persistently  that  he  was  not 
sick.  Memory  for  recent  events  was  in  general  poor.  Er- 
rands easily  forgotten.  Lost  in  the  street.  Complaint  of 
corpse  odors  round  him.  Everybody  is  looking  at  him  and 
making  fun  of  him.  He  was  apt  to  insult  bystanders.  He 
was  afraid  of  German  spies.  Things  in  shops  angered  him 
as  they  seemed  to  him  to  be  of  German  manufacture. 

There  were  frequent  periods  of  depression,  with  pallor  and 
no  spontaneous  speech  for  some  hours  to  a  half-day.  Head- 
aches coming  on  and  stopping  suddenly. 

As  to  diagnosis,  the  first  impression,  say  Pitres  and  Mar- 
chand,  was  that  of  general  paresis.  The  progress  of  symp- 
toms after  the  shock  was  consistent  with  this  diagnosis.  The 
mental  state  and  the  physical  findings  seemed  consistent, 
although  the  pupils  were  normal.  His  partial  insight  into 
his  symptoms  was  not  inconsistent  with  the  diagnosis.  He 
had  a  characteristic  self-confidence.  There  had  been  four 
stillbirths  (two  twins);  two  children  are  alive,  ii  and  13. 
Typhoid  fever  at  30.  Syphilis  denied.  No  mental  disease 
in  the  family. 

The  patient  had  never  done  military  duty,  having  been 
invalided  for  "right  apex."  But  he  had  volunteered  and  been 
accepted  in  September,  19 14. 

How  was  Lieutenant  R.  cured?  Apparently  by  rest  in 
the  Centre  Neurologique.  Pitres  and  Marchand  do  not 
speak  of  the  subtle  relation  between  mental  state  and 
the  idea  of  non-return  to  military  service.  This  motive 
might  still  work  even  if  Lieutenant  R.  kept  protest- 
ing sincerely  that  he  wanted  to  go  back  into  military 
service. 


34  SYPHILOPSYCHOSES 


War    strain;     shell    explosion;    unconsciousness. 
Sensory  and   motor   disorders.     Subject   an   old 

cwnhilitir 


syphilitic. 


Case  27.     (Karplus,  February,  191 5.) 

A  captain,  34,  was  under  much  stress  and  strain  in  the  field 
and  gave  himself  over  to  excesses  of  alcohol  and  tobacco. 
August  25,  1914,  at  the  Krasnik  battle  he  suddenly  saw  at  his 
right  a  gleam  of  fire  and  was  afterward  able  to  remember  very 
distinctly  the  words  of  a  lieutenant  standing  near  by,  "The 
man  is  dead."  Three  or  four  hours  later  he  came  to  himself 
at  a  relief  post,  vomited  and  bled  a  good  deal  from  nose  and 
mouth.  He  heard  later  that  he  had  been  thrown  on  his 
back. 

Manual  tremors  and  general  pains  developed  in  the  next 
few  days.  Two  weeks  after  the  accident  a  slight  nystagmus 
on  looking  to  the  left  appeared,  but  there  was  otherwise  no 
disorder  of  head  or  extremities.  He  was  able  to  sit  up,  sup- 
ported by  his  arms,  and  he  was  able  to  contract  his  abdom- 
inal muscles  normally.  As  for  his  legs,  active  movements 
were  limited  and  weak.  He  could  not  lift  his  legs.  The 
paralysis  was  more  marked  distally.  He  could  walk  with  the 
support  of  two  persons,  but  was  unable  to  lift  his  feet  from  the 
ground.  The  right  upper  abdominal  reflex  was  elicited,  and 
both  patellar  reflexes  were  tolerably  active.  Cremasteric  and 
plantar  reflexes  were  absent.  Neither  of  the  Achilles  jerks 
could  be  produced.  There  was  hypesthesia  and  hypalgesia 
of  the  lower  extremities,  and  of  the  back  up  to  a  horizontal 
line  corresponding  with  the  ninth  dorsal  segment;  thermo- 
hyperesthesia and  disorder  of  vibration  sense  in  the  lower 
legs.  Both  the  motor  and  the  sensory  disorders  were  more 
marked  on  the  right  than  the  left.  Insomnia  and  battle 
dreams. 

The  gait  disorder  and  paresis  gradually  improved.  There 
was  no  alimentary  glycosuria  and  adrenalin  produced  no 
mydriasis.  In  the  course  of  several  weeks  the  patient  gained 
seven  kilograms,  began  to  sleep  well  and  showed  gradual 


SYPHILOPSYCHOSES  35 

improvement  in  his  gait  and  in  the  execution  of  various 
movements  with  his  feet.  The  abdominal  reflexes  were  now 
both  present,  but  there  were  no  plantar  reflexes  and  the 
Achilles  were  still  both  absent.  The  sensory  disorder  re- 
mained unchanged,  so  far  as  the  skin  was  concerned,  but  the 
deep  sensibility  improved.  Both  legs  from  the  knee  down 
were  somewhat  cold. 

This  man  had  had  syphilis  at  twenty-two,  had  gone  through 
an  inunction  cure,  and  repeated  W.  R.'s  came  through  nega- 
tive. He  had  suffered  from  vomiting  spells  and  anxiety  feel- 
ings for  a  number  of  years  which  had  been  diagnosed  by 
physicians  as  cardiac  neurosis.  Yet  for  a  year  before  going 
into  the  war  he  had  felt  absolutely  well. 


36  SYPHILOPSYCHOSES 


Shell-explosion:  Amnesia;  syphilitic  hemiplegia. 
Recovery  except  for  amnesia  as  to  brief  period  and 
loss  of  occupational  skill. 


Case  28.     (Mairet  and  Pieron,  July,  191 5.) 

A  man  of  40  underwent  shell  shock  June  15,  1915,  and 
had  no  remembrance  of  what  happened  up  to  July,  19 15, 
when  in  hospital  at  Tunis  he  felt  "born  again." 

Examined  in  January,  1916,  it  was  found  that  he  had  a 
left  hemiplegia  (in  fact,  he  had  a  syphilitic  hemiplegia  on  that 
side,  several  years  before,  which  had  disappeared  under  anti- 
syphilitic  treatment).  This  hemiplegia  passed,  but  he  then 
had  crises  of  depression  due  to  his  despair  at  not  being  able 
to  know  who  he  was  and  what  he  was  doing.  He  could 
speak  French  and  Spanish,  and  knew  from  the  hospital  ticket 
that  he  was  born  in  Spain;  but  he  had  no  idea  what  had 
happened  to  his  relatives  or  what  he  was  doing  in  France. 
He  had,  however,  a  very  correct  idea  of  what  happened  during 
six  months  after  July,  19 15. 

One  morning  in  April,  1916,  his  old  memories  came  back 
all  of  a  sudden  on  waking.  The  gap  was  filled  up  to  the  mo- 
ment of  the  shock.  There  was  no  gap  left  except  for  a  period 
of  about  25  days  following  the  shock.  He  now  found  that  he 
knew  a  little  English  but  that  he  had  lost  his  stenography 
as  well  as  his  professional  skill  at  typewriting. 

Re  French  statistics  for  the  occurrence  of  general  paresis, 
Lautier  found  27  cases  in  426.  Early  in  the  war,  Boucherot 
at  Fleury  received  four  cases  of  paresis  among  107  cases;  the 
majority  of  these,  however,  had  not  left  the  interior.  Con- 
siglio  in  Italy  received  two  cases  out  of  270, 

Re  hemiplegia  in  this  case,  it  may  be  inquired  whether  the 
hemiplegia  which  developed  after  the  shell  explosion  on  the 
same  side  of  the  body  on  which  the  patient  had  a  true  syphi- 
litic hemiplegia,  was  really  syphilitic  or  not.  Was  it  not, 
perhaps,  in  some  sense  psychogenic?  A  similar  question  may 
be  raised  concerning  cases  in  which  the  locus  minoris  resisten- 
tiae  becomes  the  site  of  symptoms.     See  Cases  409-414. 


SYPHILOPSYCHOSES  37 


Shell-shock:  Hysterical  blindness.  Signs  of 
cerebrospinal  syphilis:  Nevertheless,  amaurosis 
functional. 


Case  29.  (Laignel-Lavastine  and  Courbon,  March, 
1916.) 

A  soldier  of  the  class  of  1906  underwent  shell-shock  August 
13, 1914,  regaining  consciousness  20  days  later,  but  blind.  The 
light  of  the  shellburst,  he  said,  was  the  last  thing  he  had  seen. 

For  sixteen  months,  he  was  transferred  from  hospital  to 
hospital,  looked  on  sometimes  as  blinded;  sometimes  as 
feigning.  Finally,  on  the  isolation  service  of  Maison- Blanche, 
December  15,  1915,  he  received  an  ophthalmologist's  diagnosis 
namely,  hysterical  amaurosis.  At  this  time  there  were  found : 
stereotyped  winking,  with  slight  lachrymation,  a  slight  left 
external  strabismus,  limitation  in  movement  of  all  the  ex- 
trinsic muscles  of  both  eyes,  especially  to  the  right  and  in 
convergence  and  elevation;  pupils  slightly  smaller  than 
normal  —  and  the  general  impression  of  a  genuinely  blinded 
or  amblyopic  subject.  He  seemed  to  be  able  to  distinguish 
faint  whitish  spots,  without  contour  or  color,  in  objects 
brought  to  a  distance  of  at  least  40  cm. 

He  also  complained  of  bad  feelings  inside  his  head  on  the 
left  side,  and  he  proved  to  have  a  left-sided  hemianesthesia 
of  hysterical  nature.  There  were  no  other  sensory  disorders 
and  no  reflex  disorders. 

The  nasolabial  fold  on  the  left  side  was  flattened  out,  and 
there  was  also  on  the  same  side  a  slight  diminution  in  the 
lower  abdominal  skin  reflexes,  and  no  response  to  plantar 
stimulation.  Examination  of  the  mouth  showed  leuco- 
plakia,  and  the  history  showed  that  the  man's  fifth  child 
was  bom  before  term  and  died  at  two  months.  Lumbar 
puncture  yielded  lymphocytosis  (55  cells)  and  an  excess  of 
albumin.  The  fundus  examination  showed  a  slight  papillary 
disorder,  suggesting  a  retrobulbar  affection  of  the  optic  nerves. 

However,  the  preservation  of  the  pupil  reflexes  seemed  to 
indicate  that  nine-tenths,   at  least,   of  the  amaurosis  was 


38  SYPHILOPSYCHOSES 

functional.  After  mercurial  treatment  the  headache  grew 
less  and  the  man  was  able  to  see  somewhat  better  with  his 
right  eye. 

Laignel-Lavastine  and  Courbon  suggest  that  there  was  a 
dynamic  disorder  in  this  case,  bearing  the  same  relation  to 
vision  as  mental  confusion  bears  to  the  process  of  ideation. 
Analogous  phenomena  have  been  found  in  the  sense  of  hearing, 
in  such  wise  that  the  victims  can,  as  it  were,  passively  hear 
but  do  not  listen. 

Re  functional  eye  cases,  see  below,  especially  Cases  432- 

437. 


SYPHILOPSYCHOSES  39 

Shell  shock  (functional)  phenomena  m  a  syphilitic. 


Case  30.     (Babonneix  and  David,  June,  191 7.) 

A  marine,  26,  on  land  service  March,  1916,  was  buried  by 
the  explosion  of  a  large  calibre  shell  which  killed  most  of  his 
comrades.  He  remained  for  a  time  in  a  sort  of  lethargy. 
Coming  to,  he  found  himself  victim  of  a  right  hemiplegia  and 
deaf  mutism,  which  phenomena  vanished  under  electricity. 

In  July,  however,  he  had  to  be  sent  to  a  hospital  on  account 
of  his  sufferings,  which  received  the  diagnoses  commotio 
cerebri,  disorder  of  consciousness,  disorientation,  delirium, 
amnesia,  over-emotionality.  He  was  sent  back  to  the  front 
in  December,  1916,  but  promptly  reported  sick,  with  head- 
aches and  insomnia. 

Examination  showed  nonorganic  nervous  disorders,  con- 
sisting in  a  variable  and  patchy  anesthesia  of  the  legs,  anes- 
thesia of  the  conjunctiva  and  pharynx,  and  over-reaction, 
with  sighing,  during  the  course  of  the  examination.  The 
organic  signs  were:  exaggeration  of  tendon  reflexes,  equili- 
bration disorder,  and  incapacity  to  stand  on  one  foot  or 
execute  a  half  turn  or  to  stand  still  with  eyes  closed,  and 
disorder  of  position  sense.  The  lumbar  puncture  showed  no 
cells,  a  slight  globulin  reaction,  and  an  albumin  titer  within 
the  normal.  There  was  a  leucoplakia  and  a  positive  W.  R. 
The  man  was  emaciated,  febrile,  and  showed  signs,  with  the 
X-ray,  of  bronchial  lymph  node  disease.  According  to  Babon- 
neix and  David,  the  normality  of  the  fluid  indicates  that  the 
phenomena  here  were  Shell-shock  phenomena,  despite  the 
indisputable  syphilis  of  the  blood  serum. 

Re  occurrence  of  functional  phenomena  in  syphllltlcs, 
Freud's  remark  may  be  recalled  to  the  effect  that  a  large 
proportion  of  his  hysterics  and  other  psychoneurotics  are 
the  offspring  of  syphilitics. 

Consider  in  this  connection  also  Case  28 :  an  old  syphilitic 
hemiplegia  was  followed  by  a  probably  psychogenic  or  hy- 
sterical hemiplegia  on  the  same  side. 


40  SYPHILOPSYCHOSES 

Vestibular  symptoms  in  a  neurosyphilitic. 


Case  31.     (GuiLLAiN  and  Barre,  April,  1916.) 

A  soldier,  Colonial,  29,  was  twice  in  the  6th  Army  neuro- 
logical centre.  The  first  time,  February,  1916,  he  was  under 
observation  for  astasla-abasia,  having  been  invalided  twice 
for  this  disease,  —  once  In  191 5.  This  man  had  had  syphilis 
at  21,  and  was  then  taken  care  of  at  Saint-Louis  Hospital  and 
at  Cochin.  A  volunteer  for  the  duration  of  war,  September, 
19 14,  he  had  intermittent  disorders  of  station  and  walking, 
which  caused  his  invaliding  January,  191 5.  As  the  trouble 
stopped,  he  asked  to  go  back  to  the  front  in  September,  but 
the  same  difficulty  reappeared  with  fatigue,  and  he  was  sent 
to  the  army  neurological  centre.  When  standing,  there  was 
a  ceaseless  trembling  of  the  whole  body  but  especially  of  the 
legs,  with  tendency  to  propulsion.  In  walking  also,  there 
was  a  trepidant  abasia,  sometimes  dizziness,  and  even  a 
sudden  fall.     Standing  on  one  foot  he   trembled   and   fell. 

Examined  on  his  back,  muscular  strength  was  found  In- 
tact in  all  limbs,  and  there  was  no  trembling  or  incoordination 
or  Intention  tremor  In  the  performance  of  any  movements, 
though  there  was  a  slight  trembling  of  the  raised  fingers  and 
hand.  Reflexes  were  normal.  The  right  pupil  was  dilated; 
the  left  pupil  reacted  sluggishly.  There  were  lateral  nystag- 
miform movements  to  the  left.  Caloric  nystagmus  appeared 
from  the  right  ear  In  15  seconds,  from  the  left  In  30.  Rotatory 
nystagmus  appeared  In  35  seconds  on  both  sides.  Lumbar 
puncture  yielded  a  fluid  with  a  slight  lymphocytosis;  al- 
bumin, .3  grams;   chloride,  7.30;   sugar  normal. 

Rest  In  bed  improved  the  astasla-abasia,  and  the  man  was 
sent  back  to  his  corps,  February  20,  191 6.  He  came  back 
March  16,  having  had  a  dizzy  spell,  with  suffocation  feeling 
and  a  fall,  whereupon  the  trepidant  astasla-abasia  had  re- 
appeared. There  were  none  of  the  so-called  defensive  re- 
flexes. The  neuromuscular  excitability  of  gastrocnemii  was 
less  on  the  right  than  on  the  left.  A  von  Graefe  sign  was 
sometimes  found ;  no  diplopia  save  on  looking  far  to  right. 


SYPHILOPSYCHOSES  4I 

Lay  reflections  on  syphilis :     Suicidal  attempts. 


Case  32.     (Colin  and  Lautier,  July,  1917.) 

A  man  was  called  to  the  auxiliaries  at  the  outbreak  of  the 
war,  and  served  as  stretcher-bearer  at  the  Mame.  He  then 
became  an  attendant  at  the  Grand- Palais.  Acquiring  gonor- 
rhoea, he  was  cared  for  but  he  grew  depressed.  The  blood 
was  examined  and  the  W.  R.  found  positive.  The  physician 
immediately  made  known  the  result  without  circumlocution, 
and  knowing  vaguely  that  the  W.  R.  meant  syphlHs,  the 
patient  felt  an  Irresistible  impulse  to  suicide,  and  cut  his 
throat.  It  seems  that  he  had  often  before  said  that  if  he 
got  syphilis  he  would  kill  himself.  Recovering  from  his 
wound,  he  was  Invalided  to  Vlllejulf,  Sept.  19,  19 16,  breath- 
ing through  a  cannula  and  responding  to  questions  In  writing. 
He  had  always  been  a  nerv^ous  and  emotional  man,  a  farmer 
in  Auvergne;  he  was  married  and  the  father  of  several 
children. 

Examination  showed  that  the  recurrent  nerves  had  been 
cut  and  that  the  man  must  needs  always  breathe  through  the 
cannula.  In  point  of  fact,  the  W.  R,,  only  partially  positive 
at  the  outset,  did  not  Indicate  syphilis,  and  the  gonorrhoea 
was  now  cured.  But  though  the  patient  knew  these  facts,  his 
hypochondria  persisted,  basing  itself  upon  the  suicidal  wound. 
He  said  that  his  larynx  had  been  stolen  and  he  wondered 
why.  He  said  that  he  had  violent  crises  of  suffocation,  though 
there  was,  as  a  matter  of  fact,  no  difficulty  with  his  breath- 
ing. Verdigris,  he  said,  was  forming  on  his  cannula.  Self- 
accusations  about  the  suicide  developed.  On  being  trans- 
ferred to  his  department  asylum,  he  made  a  suicidal  attempt 
on  the  trip. 

Of  course  the  gonorrhoea  may  have  served  as  a  partial 
factor  In  the  genesis  of  the  case,  and  his  own  mental  attitude 
toward  the  contraction  of  syphilis  may  have  been  another 
factor. 


42  SYPHTLOPSYCHOSES 

The  imitation  of  chancre. 


Case  33.     (Pick,  July,  1916.) 

A  married  German  farmer,  32,  was  in  Prague  hospital  in 
1908  during  his  period  of  military  service  and  was  then 
treated  by  inunction  for  a  local  chancre.  He  was  given  mer- 
curial injections  a  year  later  for  rash. 

In  1912,  he  had  signs  of  syphilis  in  the  mouth. 

He  was  sent  home  from  service  in  191 3,  with  ulcers  of  hand. 

At  the  beginning  of  the  war  he  was  found  to  have  ulcers  on 
the  knee,  legs,  and  mouth,  and  was  sent  home  for  six  months. 

Again  called  up  in  191 5,  the  ulcers  were  still  in  evidence;  he 
got  inunctions  in  a  military  hospital  four  months. 

He  was  sent  to  his  corps  in  July  and  had  no  relapse  until 
July,  191 6,  when  he  was  detailed  for  active  service.  There- 
upon, ulcers  began  on  the  left  hand  and  right  leg.  He  re- 
ported sick,  but  was  sent  nevertheless  to  the  front.  In 
hospital  he  was  found  to  have  several  scars  about  one  inch 
across  on  each  leg,  on  the  dorsum  of  the  left  hand,  at  the 
right  of  the  left  index  finger,  and  elsewhere.  These  scars 
were  deeply  pigmented.  One  of  them  was  square!  There 
were  other  recent  ulcers  that  closely  resembled  tertiary  ulcers. 
The  most  recent  of  these  ulcers  was  angular,  intensely  red, 
and  showed  remains  of  a  collapsed  vesicle.  There  was  a 
deep  dark  scab  on  the  mucous  membrane  of  the  left  cheek. 

There  is  no  doubt  that  these  ulcers  were  produced  by  some 
caustic,  the  nature  of  which  remains  unknown.  The  patient 
had,  however,  been  able  to  evade  military  obligation  during 
peace  time  and  for  two  years  during  war  time. 

Re  simulation,  according  to  Pick,  some  5  to  7  per  cent 
venereal  diseases  in  the  German  army  have  been  simulations. 
Gonorrhoea  Is  simulated  by  soap,  balanitis  by  cantharides, 
soft  chancre  by  soap  and  mercuric  or  mercurous  chloride 
mixed,  hard  chancre  by  a  fluid  or  powder  containing 
NaOH,  Na2C0,  and  NaCl.  Secondary  syphilitic  signs  are 
imitated  by  cantharides  or  garlic,  producing  scrotal  derma- 
titis.    Tertiaries  are  imitated  with  caustics. 


SYPHILOPSYCHOSES  43 

Ramon  to  Rosina :     a  soldier's  letter  to  his  fiancee. 


Case  34.     (BuscAiNO  and  Coppola,  January,  191 6.) 

"  I  am  here  to  stay  a  month.  Believe  me,  it  is  better 
here  than  in  the  army.  There  is  a  rule  that  we  may  eat 
as  much  as  we  can  and  everything  is  of  the  very  best. 
The  servants  treat  us  like  brothers.  Do  not  think  it 
is  a  nuisance  to  be  inside  four  walls  with  a  wee  bit  of  a 
garden.  No,  indeed!  But  I  have  got  to  act  the  fool 
and  from  the  very  first  day  I  began  to  play  and  act 
crazy  with  a  kitten,  so  that  if  you  had  seen  me  you 
would  say:  ''  Ramon  is  really  crazy."  Rosina,  dear, 
to  avoid  paying  taxes  you  have  got  to  be  a  smuggler. 
And  now  that  I  am  at  the  ball  I  have  got  to  dance. 
I  want  to  see  if  after  all  the  suffering  I  cannot  get 
something  better.  I  am  better  off  here  than  at  the 
regiment.  I  sleep  in  a  fine  warm  bed,  and  they  have 
only  cold  straw ;  I  have  good  food  and  drink  and  plenty  of 
milk,  and  they  have  poor  food  and  drink  and  so  little. 

"  I  expect  to  go  home  in  about  three  weeks.  I 
would  have  been  there  before  if  some  fool  of  a  spy  at 
our  place  had  held  his  tongue  and  minded  his  own 
business.  At  the  same  time,  Rosina,  dear,  remember 
what  I  told  you  at  Leghorn :  that  they  had  some  officers 
sent  there  to  get  information  and  instead  of  going  home 
they  asked  somebody  else  and  were  told  that  I  had 
never  been  sick  and  had  never  had  neurasthenia. 
When  this  information  was  got  from  the  officers  I  was 
called  to  the  office  and  they  read  to  me  that  all  that  I 
had  said  and  done  was  not  true.  I  kept  on  acting  the 
fool,  and  as  they  were  still  doubtful  they  sent  me  here, 
where  there  is  a  professor  who  passes  me  every  morning 
in  the  garden  and  says:  "  How  are  you?"  I  always 
say:  "  I  am  the  same,  "  acting  like  a  crazy  man.  Let 
me  tell  you,  Rosina  dear,  not  to  say  anything  contrary 
to  this  in  your  letters  because  they  open  and  read 
everything  in  order  to  find  out  everything  that  happens 
and  everything  that  is  said.  Now  what  you  must  do  is 
to  ask  me  how  I  am  feeling,  and  whether  my  headaches 
are  gone,  and  whether  I  have  them  all  the  time  as 
formerly,  and  any  other  trifle  that  will  help  me." 

Rosina's  fiance  had  a  strongly  positive  W,  R.  in  the  serum. 
It  was  negative  in  the  fluid.     He  was  returned  to  the  front. 


II.   HYPOPHRENOSES 
(THE  FEEBLE-MINDED   GROUP) 


Moron  of  use  at  front  (alienist's  report). 


Case  35.     (Pruvost,  1915.) 

Vigouroux  reports  concerning  a  tanner  of  19  who  could 
not  read,  write  or  calculate  (3  plus  8  equals  14)  and  had  been 
of  the  1 91 6  class  in  an  infantry  regiment  at  Brest,  on  the 
occasion  of  his  asking  to  be  sent  to  the  front  more  speedily: 

]\Iental  weakness,  with  insufficient  school  and  theoretical 
knowledge  but  with  the  ability  to  assimilate  practical  ideas, 
though  not  knowing  how  to  read,  write  or  calculate;  seems  to 
have  earned  his  living  in  several  lines.  "  As  a  soldier,  he 
does  not  know  the  insignia  of  the  different  ranks  but  under- 
stands how  to  obey  a  superior  officer.  Understands  a  gun 
and  can  tell  a  chargeur  from  a  Le  Bel  gun.  Moreover  he 
seems  to  be  perfectly  stable,  fixed  in  his  wishes,  persistently 
and  intelligently  wants  to  go  to  the  front  and  kill  Boches. 
He  appears  to  be  well  disciplined  and  educable.  Although 
feebleminded,  he  appears  to  us  able  to  be  useful  at  the  front, 
though  he  should  not  be  employed  in  any  undertaking  re- 
quiring initiative  or  foresight." 


44 


HYPOPHRENOSES  45 

An  imbecile,  superbrave. 


Case  36.     (Pruvost,  1915.) 

A  loquacious,  active  fellow,  22,  with  very  slight  school 
knowledge  and  no  idea  of  military  ranks  (treated  his  superiors 
like  his  comrades),  was  often  punished  in  the  barracks.  He 
did  not  get  on  well  with  his  instructors.  His  activities 
were  never  interrupted  by  any  obstacles  or  by  derision. 
He  kept  singing  and  talking  enthusiastically  during  the  mo- 
bilization.    He  was  the  butt  of  his  section. 

At  Dinant  he  did  very  well ;  though  his  section  was  losing 
a  good  many  men  he  remained  calm.  He  was  careless  of 
danger  and  remained  at  his  post  firing  ceaselessly  at  the 
enemy  and  giving  a  magnificent  example  to  the  few  comrades 
who  remained  with  him.  In  fact,  he  remained  so  long  in  his 
shelter  that  he  was  surrounded  and  taken  prisoner.  He 
escaped,  swam  the  Meuse  and  got  back  to  his  regiment. 


An  imbecile  of  service  in  barracks  work. 


Case  37.     (Pruvost,  1915.) 

A  farmer,  36  (father  alcoholic,  mother  always  sick,  two 
brothers  at  the  front ;  patient  had  typhoid  at  an  unknown  age ; 
had  gone  to  school  at  13  but  "  learned  nothing";  worked  in 
fields  with  his  brother  who  gave  him  some  pennies  on  Sunday) , 
was  put  into  the  auxiliary  service  by  the  Council  at  20. 
Patient  said  he  was  not  strong  enough  for  this  service .  I  n  1 9 1 4 
the  Council  reconsidered  the  case  and  put  him  into  a  regiment 
of  infantry.  He  could  not  be  given  military  Instruction  or 
execute  the  most  simple  drilling  manual.  He  said  that  4 
plus  2  equalled  7 ;  4  plus  3  equalled  5.  He  was  of  an  excellent 
character,  very  docile  and  easily  directed.  He  did  all  his 
comrades'  barracks  work  and  was  very  proud  because,  as 
he  said,  "  I  do  everything  they  tell  me  to  do."  He  was 
happy  in  working,  everybody  v/as  good  to  him,  but  he  had 
no  comrades.  He  had  no  general  knowledge  and  knew  noth- 
ing about  the  war  but  that  they  were  fighting  the  Boche. 


46  HYPOPHRENOSES 

Re  Imbeciles,  Colin,  Lautier  and  Magnac  found  amongst 
1000  soldiers  entering  Villejuif,  53  imbeciles.  Twenty-four 
of  them  had  been  either  exempt  or  retired  at  the  outset  of 
the  war,  when  military  surgeons  had  reviewed  them  and 
considered  them  fit  for  service.  Several  of  the  29  others 
also  had  shown  previous  evidence  of  imbecility. 

Of  course,  French  military  surgeons  may  have  felt  that  a 
number  of  these  men  would  be  of  just  such  service  In  bar- 
racks and  otherwise  as  Case  37  (Pruvost).  But  for  one  or 
two  cases  like  Cases  37  and  41  of  Pruvost,  there  are  great 
numbers  of  other  Imbeciles  who  prove  quite  useless  In  the 
army.  Two  of  the  Villejuif  cases  had  been  volunteers:  one 
volunteer  declared  that,  if  he  had  been  Intelligent,  he  never 
would  have  enlisted!  Ten  cases  proved  unable  to  use  a 
gun;  one  turned  his  gun  upon  his  mates.  One  regularly 
forgot  the  password.  One  (see  Case  42  of  Lautier)  thought 
the  war  too  long  and  tried  to  take  command  of  the  company 
in  order  to  finish  the  war  one  way  or  the  other.  Three  of 
the  imbeciles  had  to  be  evacuated  for  desertion  (unmoti- 
vated fugues) ;  two  of  them  cursed  their  officers.  Some  of 
the  Imbeciles  had  an  emotional  diarrhoea  throughout  their 
service. 

Colin  suggests  that  line  officers  and  military  surgeons 
ought  to  agree  that  these  men  are  not  fit  for  service,  and  that 
the  civil  authorities  of  the  home  towns  should  advise  the 
review  boards  about  known  imbeciles  and  criminals.  In 
point  of  fact,  previous  knowledge  of  Imbecility  could  have 
been  obtained  quite  readily  in  27  of  the  53  cases  observed 
by  Colin, 


HYPOPHRENOSES  47 

A  feeble-minded  inventor. 


Case  38.  (Laignel-Lavastine  and  Ballet,  1917.) 
A  jockey  of  Nimes,  31,  entered  the  service  May  15,  1917. 
He  retired  before  the  war.  He  was  in  the  auxiliaries  at  the 
moment  of  mobiUzation.  Nothing  is  known  as  to  any  patho- 
logical episodes  in  his  past.  He  said  he  had  been  a  poor 
scholar,  had  left  the  primary  school  at  eleven  hardly  knowing 
how  to  write  or  spell,  but  he  had  a  lively  imagination  and  was 
a  happy-go-lucky  youth,  playing  many  tricks  on  the  trades 
people.  He  tried  a  variety  of  ideas  in  the  industrial  or  com- 
mercial world  with  very  varying  success.  He  had  a  mechani- 
cal taste.  The  Colonial  Exposition  at  Marseilles  caused 
him  to  float  a  variety  of  projects,  from  that  of  having  the 
visitors  photographed  on  a  camel  to  the  sale  of  lemonade. 
He  said  he  had  been  a  jockey  and  then  a  trainer  and  had 
finally  become  a  valet  de  jockey  at  Maisons  Lafhtte.  He  was 
a  gambler  and  invented  a  "  system."  He  made  various 
inventions  in  relation  to  horses.  At  the  end  of  19 14  he  had 
plans  for  a  bomb  thrower  and  placed  his  discovery  at  the 
service  of  the  War  Minister.  He  was  not  discouraged  by  the 
lack  of  success  of  the  bomb  thrower.  He  now  made  an 
aerial  torpedo  carrier.  He  had  the  idea  of  the  tanks. 
However,  he  found  the  secret  of  his  torpedo  carrier  printed 
in  a  magazine.  There  was  a  slight  difference  between  the 
German  apparatus  and  his  own. 

From  this  time  he  began  to  be  mistrustful,  and  now  he 
jealously  avoided  entering  into  any  details  about  his  inven- 
tions and  he  did  not  let  his  officers  see  his  plans.  The  Com- 
mandant offered  to  give  a  place  in  the  safe  to  his  documents, 
but  he  could  not  embrace  the  offer.  He  now  invented  a 
counter-torpedo  machine.  He  went  on  leave  to  Paris,  asked 
an  audience  of  the  Minister  of  Marine,  who  put  him  in 
relation  to  the  Committee  on  Inventions,  who  put  him  off, 
desiring  that  he  should  forward  all  his  plans.  He  emerged 
from  one  of  his  interviews  so  excited  that  there  was  a  scandal 
on  the  public  street  and  the  police  commissary  evacuated  him 
to  Val-de-Grace,  but  the  patient  says  he  does  not  remember 


48  HYPOPHRENOSES 

this  incident.  He  came  on  service  of  Laignel-Lavastine 
May  15.  He  shortly  wrote  again  to  the  Minister,  who 
again  referred  him  to  the  Committee  on  Inventions.  He 
protested  to  the  President  of  the  RepubHc  and  wrote  directly 
to  the  King  of  England,  who  referred  him  to  the  Military 
Administration.  He  is  now  occupied  in  creating  a  machine 
to  destroy  the  first  line  trenches  and  continues  to  write  to 
the  Ministry.  He  has  documents  buried  underground  in  a 
secret  place.  He  still  talks  with  great  vivacity  of  his  dis- 
coveries. 

According  to  Laignel-Lavastine,  we  deal  with  a  feeble- 
minded person  who  has  for  many  years  had  a  delire  raison- 
nant  of  the  inventing  group. 

Re  feeblemindedness  in  the  British  Army,  Shuttleworth 
found  70  who  had  joined  from  special  schools  for  the  feeble- 
minded in  London,  and  100  from  Birmingham  in  the  year 
191 5.  The  institutional  "children"  were  in  general  good  at 
drilling  and  obeying.  One  of  them,  given  to  lying  and 
stealing,  got  into  constant  trouble  in  Flanders. 

Sir  George  Savage  stated  that  he  had  sometimes  run  the 
risk  of  allowing  enlistment  of  men  who  had  shown  earlier 
in  life  a  weakness  for  lying  and  pilfering,  and  remarked  that 
such  men  might  make  good  soldiers.  A  case  like  the  above 
(38)  would  run  counter  to  this  view.  On  this  matter,  see 
below  Case  183  (Henderson),  one  of  pathological  lying. 


HYPOPHRENOSES  49 

An  imbecile  who  walked  lame. 


Case  39.     (Pruvost,  191 5.) 

A  soldier,  20,  eight  days  after  being  called  to  the  colors, 
complained  of  pain  in  the  knee  and  hip.  He  was  observed 
for  18  days  in  hospital  and  then  sent  back  to  his  company; 
but  he  continued  to  complain  of  the  pains,  and  the  regimental 
surgeon  sent  him  to  a  neurological  center  where  the  joints 
were  found  to  be  normal  and  where  no  sensory,  motor  or 
reflex  disorders  were  in  evidence.  The  man  continued  to 
walk  lame  and  insisted  he  could  not  get  about  without  a 
cane.  He  also  complained  of  his  mouth  and  his  belly  and, 
though  he  was  very  ruddy,  said  he  was  d  bout  de  forces. 

It  was  a  question  of  simulation.  The  man,  however,  was 
a  feebleminded  person  who  could  not  read,  write  or  calculate. 
He  was  invalided  as  such. 


Enlistment  to  improve  character. 


Case  40.     (Briand,  February,  1915.) 

A  village  boy  had  passed  for  simple  ever  since  typhoid 
fever  at  8.  He  had  learned  to  read  and  write,  but  had  always 
been  impulsive  and  subject  to  fugues,  running  to  see  his 
grandmother,  or  off  as  a  truant.  It  was  decided  that  he,  at 
19,  should  enlist  to  improve  his  character.  But  one  fine  day, 
even  before  the  war,  he  deserted.  He  said,  in  explanation, 
that  he  had  lost  his  way,  and  he  was  being  examined  mentally 
when  mobilization  began. 

He  looked  ape-like,  with  spread  ears;  had  a  low  forehead,  a 
head  flattened  behind,  an  asymmetrical  face,  prognathous 
jaws,  an  arched  palate,  and  defective  teeth.  He  talked  freely 
of  homosexual  relations,  and  said  he  wandered  off  because 
it  occurred  to  him  to  do  so.  He  was  determined  to  be  unfit 
for  service. 


50  HYPOPHRENOSES 

An  imbecile  who  may  be  sent  to  the  front. 


Case  41.     (Pruvost,  1915.) 

A  Parisian  sandwich  man,  25,  of  unknown  parentage  and  a 
state  ward,  placed  out  with  a  armer  at  12,  escaping  with  a 
friend  to  Bordeaux  at  14,  thence  leading  a  wild,  improvident 
life  at  Lyons,  Marseilles  and  Paris,  sleeping  in  fields  and 
hedges,  earning  22  sous  a  day  but  in  no  case  mixing  with  the 
police,  was  examined  for  physical  inefficiency  at  20  years. 
He  wanted  to  enlist  but  was  refused.  He  insisted  and  was 
very  proud  of  the  fact  that  he  got  in  as  the  Major  said 
to  them,  "  Let  him  go  in."  He  could  hardly  read,  write  or 
calculate  but  was  by  reason  of  his  adventurous  life  full  of 
practical  resources.  He  w^as  irascible  and  frequently  crimed, 
whereupon  he  would  cry  under  the  Captain's  window,  "  Rob- 
ber band,  idiots,  I  shall  write  to  the  Minister."  He  was 
passionately  fond  of  military  life,  though  he  had  but  the 
vaguest  notions  about  the  commands,  the  names  of  generals 
and  the  like.  He  wanted  to  drill.  His  comrades  played 
practical  jokes  upon  him  asking  him  to  look  for  a  trajectory, 
for  the  squad's  umbrella  and  the  key  to  the  drill  ground. 
They  also  told  him  he  had  been  proposed  to  be  corporal, 
whereupon  he  was  greatly  overjoyed  and  immediately  sewed 
stripes  on  his  sleeve  and  began  to  give  commands.  He  said 
if  they  put  him  among  the  auxiliaries  he  would  throw  the 
adjutant  in  the  water.  He  sang  and  swung  his  gun  with 
joy  when  he  went  to  the  front.  He  thought  there  were  stripes 
hanging  to  the  barbed  wire  and  wanted  to  pick  as  many 
as  possible.  Such  a  man  may  be  safely  sent  to  the  front 
although  he  will  bear  watching.  At  the  date  of  report 
this  man  had  been  at  the  front  two  months  doing  very  well. 

Re  the  comparative  success  of  the  Germans  in  the  matter 
of  excluding  imbeciles,  Meyer  found  that  8  per  cent  of  the 
mental  cases  in  the  army  were  cases  of  mental  defect. 


HYPOPHRENOSES  5I 

Imbecile  with  sudden  initiative. 


Case  42.     (Lautier,  1915.) 

A  soldier,  41,  a  farmer,  from  the  Department  of  the  Marne, 
married,  childless,  was  called  to  the  colors  August  31,  1914. 
He  was  on  guard  duty  until  May,  19 15,  watched  prisoners 
until  October  and  was  finally  sent  to  the  front,  February,  1916, 
where  he  fell  sick. 

"  He  was  tired  in  his  head."  "  His  commanding  officer 
made  him  drill  without  rhyme  or  reason ;  he  would  have  been 
able  himself  to  have  commanded  with  greater  intelligence." 
He  once  attempted  to  put  himself  at  the  head  of  the  company 
to  lead  them  against  the  Boche ;  this  idea  arrived  to  him  all  of 
a  sudden  in  a  phase  of  perfect  confidence  and  sang  froid.  He 
thought  his  comrades  would  follow  him  and  that  the  officers 
would  do  likewise.  He  hoped  thus  to  be  able  to  end  the  war 
one  way  or  the  other.  He  was  getting  tired  of  the  war  and 
regretted  his  family  life  and  kept  saying  that  this  was  no 
existence  for  family  men.  "  We  ought  to  attack  or  ask  for 
peace."  No  one  followed  him  and  his  comrades  said  he  was 
un  peu  fou  but  he  did  not  share  this  opinion. 

In  point  of  fact  he  hardly  knew  how  to  read  or  write  and 
at  home  lived  with  his  relatives,  submitting  himself  entirely 
to  their  guidance.  He  was  much  afraid  of  being  punished  and 
often  feared  that  he  had  done  badly  as  he  had  trop  de  con- 
science. He  was  non-alcoholic  and  without  hereditary  or 
acquired  neuropathic  taint.  He  had  no  pronounced  stigmata 
of  degeneration.  He  was  rather  reticent  about  certain 
mystical  ideas  of  a  political  tinge.  At  Villejuif,  whither  he 
was  brought  February  17,  1916,  he  received  a  diagnosis  of 
imbecility. 


52  HYPOPHRENOSES 

Emotional  fugue  in  a  subnormal  subject. 


Case  43.     (Briand,  February,  1915.) 

A  soldier  in  the  Territorial  Army,  40,  appeared  before 
the  examining  board  in  a  depressed,  dejected-looking  state, 
speaking  slowly  but  collectedly  and  lucidly.  Mobilized  the 
second  day,  this  man  was  much  afraid  that  he  could  not 
get  through  the  marches,  and  asked  for  a  special  examination 
to  determine  whether  his  feet  did  not  make  him  unsuitable 
for  fatigue.  Two  physicians  thought  he  was  unsuitable  for 
marching,  and  another  thought  he  put  it  on.  A  trial  march 
was  not  executed  well.  He  was  kept  in  barracks  but  jumped 
the  wall,  put  on  civilian  clothes,  and  made  off  for  Paris.  But 
a  relative,  warned  by  his  wife,  finally  got  him  to  go  to  the 
authorities.  He  was  told  that  he  ought  to  return  in  the 
afternoon,  when  suddenly  he  was  arrested. 

It  seems  that  the  man  relied  on  the  opinion  of  the  two 
physicians  and  discounted  that  of  the  third.  He  thought 
himself  the  victim  of  an  injustice,  and  not  knowing  how  to 
get  on,  it  occurred  to  him  that  he  would  abandon  the  regiment 
and  get  out  of  the  difficulty.  It  was  without  resistance,  how- 
ever, that  he  gave  himself  up  as  a  prisoner.  This  fugue  was 
neither  unconscious  nor  amnestic,  nor  was  it  due  to  an  ir- 
resistible Impulse;  nor  can  we  say  that  it  was  due  to  a 
genuine  intellectual  disorder.  It  was  an  emotional  fugue,  and 
partly  due  to  the  man's  long-standing  depression.  It  seems 
that  he  had  inherited  this  character  from  his  father.  He 
was  below  normal  intelligence,  had  a  very  poor  education, 
lost  his  wife,  and  grew  more  and  more  sombre.  He  married 
again,  but  this  time  a  neuropath.  He  began  to  be  preoc- 
cupied with  his  health  and  he  had  even  some  ideas  of  suicide. 
At  the  time  of  his  leaving  the  regiment,  he  had  passed  through 
a  phase  of  depression  of  about  6  months'  duration,  and  at 
this  time  had  a  number  of  hypochondriacal  ideas  with  poor 
appetite  and  loss  of  weight. 


HYPOPHRENOSES  53 


Diagnostic  dispute  between  regimental  surgeon  and 
alienist. 


Case  44.     (Kastan,  January,  191 6.) 

Julius  Q.  was  sent  on  guard  April  14,  1915,  with  orders 
to  remain  there.  While  on  guard  he  made  a  noise  and  made 
a  movement  as  if  to  take  a  knife  from  his  pocket.  Ordered 
to  empty  his  pockets,  he  attacked  the  other  guards.  The 
witnesses  said  that  he  was  drunk. 

Upon  examination,  it  appeared  that  he  had  recognized  and 
called  by  name  those  present  in  the  guardhouse,  despite  his 
supposed  intoxication.  There  were  red  spots  on  the  skin 
and  a  certain  amount  of  analgesia.  His  powers  of  compu- 
tation and  reasoning  were  poor.  He  was  unable  to  explain 
the  meaning  of  a  picture  shown  him.  He  maintained  that 
he  had  an  indomitable  desire  for  drink.  A  diagnostic  draught 
of  alcohol  yielded  no  reaction.  Upon  dismissal,  he  got  drunk 
at  once  again,  and  had  again  to  be  imprisoned  in  a  state  of 
excitement.  What  the  outcome  in  this  case  was  is  not  stated 
by  Kastan. 

The  previous  history  seems  important.  Julius  Q.  had  been 
a  state  ward.  He  had  escaped  several  times  from  the  in- 
stitution but  had  always  to  be  brought  back  again  because 
he  could  not  be  trained  at  home.  He  had  once  attacked  a 
supervisor  in  the  state  institution  with  a  knife.  It  seems 
that  he  had  at  this  time  been  drunk,  having  been  brought 
back  drunk  to  the  institution. 

Two  years  before  the  war  he  had  been  taken  to  the  Breslau 
Hospital  for  the  Insane  on  account  of  fits  of  insanity.  In 
19 1 3  he  had  been  a  patient  in  Wuhlgarten  on  similar  grounds. 
The  diagnosis  there  had  been  epileptoid  degeneration,  psy- 
chopathic constitution,  imbecility,  or  epilepsy(?).  He  had 
been  convicted  of  crimes  a  number  of  times  and  put  to 
labor.     He  had  been  given  to  cruelty  in  childhood. 

Despite  this,  he  was  declared  perfectly  healthy  in  mind  and 
body  by  the  regimental  surgeon. 


54  HYPOPHRENOSES 

In  1914,  Q.  fell  suddenly  ill  in  prison  (he  was  presumably 
in  prison  for  a  military  offence),  and  smeared  the  cell  with 
feces,  saying  that  he  was  able  to  do  that  as  he  could  pay  for 
anything.  He  stared  at  the  floor  and  failed  to  answer  ques- 
tions. He  remarked,  however,  that  he  had  frequently  been 
convicted  for  breach  of  the  peace  and  assault  and  battery, 
and  he  said  his  father  had  been  a  drunkard,  and  he  acknowl- 
edged hallucinations  to  the  extent  of  saying  that  he  heard  his 
name  called  when  he  was  alone. 

The  story  of  this  case  warrants  our  Inquiring  why  such  a 
patient  was  kept  in  the  army.  He  was  kept  there  clearly 
on  account  of  the  report  of  the  regimental  surgeon,  who 
could  not  have  taken  seriously  the  previous  history  of  the 
case,  or  else  thought  the  patient  perfectly  good  cannon  fodder. 

The  hypothesis  of  syphilis  apparently  need  not  be  en- 
tertained. That  of  feeblemindedness  is  possibly  the  funda- 
mental diagnosis,  yet  epilepsy  was  considered  by  the  German 
diagnosticians,  doubtless  on  account  of  the  sudden  violent 
attacks  and  breaches  of  peace  on  the  part  of  the  patient. 
There  is  clearly  something  behind  mere  alcoholism  in  the  en- 
tire story  of  this  state  ward.  On  the  whole,  the  periodicity 
of  the  attacks  is  equally  consistent  with  the  picture  presented 
by  numerous  feeble-minded  persons,  and  the  institutions  that 
had  to  deal  with  Q.  regarded  him  rather  as  epileptoid. 
There  seems  to  be  evidence  of  actual  intellectual  defect. 
Accordingly  it  seems  wiser  to  consider  the  case  of  Julius  Q. 
one  of  feeblemindedness,  possibly  of  the  moron  group.  We 
should  then  consider  the  epileptoid  features  as  part  and 
parcel  of  the  feeblemindedness.  We  should  consider  the 
intellectual  defect  a  part  of  the  process;  and  the  uncontrollable 
impulse  to  drink,  the  sudden  violent  attacks,  and  the  cruelty 
in  childhood  would  then  be  regarded  as  merely  symptomatic 
of  the  feeblemindedness.  It  seems  clear  that  either  mental 
tests  by  the  regimental  surgeon  or  an  examination  of  the 
patient's  previous  history  would  tend  to  exclude  such  a 
patient  from  the  army. 


HYPOPHRENOSES  55 

How  can  a  rifleman  be  an  imbecile? 


Case  45.     (Kastan,  January,  191 6.) 

Anton  K.  was  down  in  the  list  as  "  missing."  He  was 
found  at  home.  He  said  his  feet  had  become  sore  from  the 
marching.  He  had  lain  down  and  become  unconscious. 
Coming  to  his  senses,  he  was  possessed  only  of  trousers  and  a 
shirt  but  he  got  a  civilian  suit  in  a  village.  He  had  gone  home 
part  way  by  train,  part  way  on  foot.  It  seems  that  he  did 
not  tell  his  father  any  details  about  his  coming  back  although 
he  expressly  denied  deserting. 

It  seems  no  mental  weakness  had  been  noticed  in  the  army. 
It  had  been  observed,  however,  that  after  seeing  the  first 
corpses  he  was  deeply  impressed  and  did  not  want  to  see  any 
more.  On  examination  in  the  hospital  he  gave  the  impression 
of  indifference  and  low  spirits.  He  had  to  be  urged  to  eat 
and  work.  No  great  amount  of  intelligence  defect  could  be 
determined,  though  his  knowledge  and  capacity  were  below 
the  average.  The  physician  examining  him  thought  his  de- 
pression was  either  caused  by  or  increased  by  his  imprison- 
ment; but  this  examiner  thought  that  the  protection  of 
Section  51  did  not  extend  to  the  patient  at  the  time  of  his 
desertion.  The  examiner  thought  that  an  examination  by  a 
psychiatrist  was  not  necessary,  though  both  judge  and 
prosecutor  urged  it. 

When  examined  in  the  clinic,  he  seemed  to  be  disoriented 
for  time.  He  claimed  to  have  been  able  to  stand  the  shoot- 
ing and  the  sight  of  the  corpses.  After  becoming  unconscious, 
he  had  wakened  and  eaten  cucumbers  and  carrots  in  the 
fields,  wandering  on  for  a  period  of  three  or  four  weeks, 
until  he  came  to  a  place  where  he  had  formerly  worked. 
The  reason  he  had  thrown  away  his  uniform  was  because 
Russians  had  been  about.  He  had  not  known  that  it  was  his 
duty  to  report  to  the  army  again. 

It  was  found  that  the  patient's  father  was  poorly  developed 
as  to  mind,  that  his  brother  was  subject  to  periodic  mental 
disturbance  so  that  he  had  to  be  watched.  It  was  found 
also  that  K.  himself  had  had  a  similar  mental  disturbance, 


56'  HYPOPHRENOSES 

lasting  a  week,  two  years  before.  Moreover  he  was  not 
considered  mentally  right  in  his  home  town.  In  fact,  no 
one  there  wondered  really  at  his  desertion  because  he  was  so 
stupid.     His  school  work  had  been  poor  and  limited. 

He  himself  said  that  his  people  were  of  sound  mind;  that 
during  school  days  he  had  felt  bad  in  his  head,  once  running 
into  the  woods  after  being  told  something.  He  was  able 
to  give  the  names  of  his  former  superiors.  His  calculations 
were  only  partly  correct.  He  was  poor  at  reasoning  and  at 
simple  distinctions ;  for  example,  asked  the  difference  between 
a  bird  and  a  butterfly,  he  replied  that  a  butterfly  was  a  bird 
too.  He  did  not  know  the  difference  between  a  river  and  a 
lake.  He  thought  Russia,  England,  and  Austria  were  the 
enemies  of  Germany. 

He  sat  about  or  lay  on  the  floor,  motionless  and  indifferent, 
with  a  newspaper  stuffed  into  his  trousers,  unoccupied  al- 
though saying  that  he  wanted  to  work,  and  even  allowing 
his  fingers  to  be  burned  by  cigarettes  he  was  smoking. 

He  was  tried  once  more  and  the  first  medical  expert  still 
adhered  to  his  former  opinion,  pointing  out  that  K.  was  a 
rifleman  and  that  only  an  intelligent  man  could  he  a  rifleman. 
The  court,  however,  accepted  Kastan's  opinion  and  granted 
K.  the  protection  of  Section  51. 

In  comment  upon  this  case,  it  seems  clear  that  ever  so 
slight  a  knowledge  of  K's  home  town  reputation  would  have 
naturally  excluded  him  from  the  army.  However,  what  is  to 
be  said  "  when  doctors  disagree,"  as  noted  by  Kastan  in  this 
very  case?  It  seems  impossible,  also,  that  his  comrades 
should  not  have  noticed  something  odd  about  him  (over  and 
above  the  deep  impression  on  seeing  the  first  dead)  which 
might  have  given  occasion  to  the  regimental  surgeon  for  a 
special  mental  examination.  However,  to  the  military  mind, 
mayhap  the  man  seemed  to  be  sufficiently  "  effective." 

Re  imbecility  in  a  rifleman,  the  compiler  has  studied  some- 
what elaborately  the  brain  of  a  feeble-minded  murderer  with 
some  North  American  Indian  blood  in  him.  This  man  was 
a  crack  shot  despite  his  subnormality.  It  would  seem  that 
the  German  regimental  surgeons  castigated  by  Kastan  as 
above  were  very  properly  so  castigated. 


HYPOPHRENOSES  57 

Hypomania  in  an  imbecile. 


Case  46.     (Haury,  August,  1915.) 

A  brusque  little  man,  of  a  somewhat  bold  and  talkative 
disposition,  though  giving  a  good  first  impression,  was  evi- 
dently a  bit  feebleminded,  though  (as  Haury  says)  of  the  ac- 
tive group.  He  had  a  sister  like  himself,  whose  children  were 
taken  care  of  by  the  State,  and  at  home  he  had  had  a  number 
of  fugues,  about  which  details  were  lacking.  It  was  soon 
evident  what  sort  of  soldier  he  would  make,  and  he  was  put 
in  one  of  the  Territorial  regiments,  but  it  was  not  noted  that 
he  had  a  genuine  mental  disorder,  as  he  was  thought  to  be 
just  a  peculiar  person. 

His  new  relations  caused  him  to  do  a  number  of  eccentric 
things.  He  shortly  proved  to  be  in  a  sort  of  rudimentary 
maniacal  state;  talkative,  restless,  scheming  rather  feebly  to 
go  back  to  his  village.  He  said  that  he  couldn't  walk  on 
account  of  corns,  and  that  these  corns  required  a  certain  drug, 
which  he  wanted  to  get  from  home.  He  said  that  he  had 
been  struck  by  lightning  twice ;  that  he  had  fires  in  his  body, 
etc.  He  wanted  only  to  be  retired  on  a  pension  of  one  or 
two  hundred  francs  so  he  could  take  care  of  his  farm,  his  hay 
and  his  fields.  There  was  no  need  of  trying  to  get  land  by 
means  of  bullets,  he  said,  since  he  had  enough. 

The  mental  disorder  of  this  man  was  much  deeper  than 
appeared,  and  in  fact,  he  did  a  number  of  dangerous  things 
compromising  the  security  of  the  entire  regiment. 

Re  the  dangerous  tendencies  of  Case  46,  see  the  remarks 
above  drawn  from  Colin,  under  Case  37. 


58  HYPOPHRENOSES 


Insubordinate  desire  to  remain  at  the  front. 


Case  47.     (Kastan,  January,  1916.) 

Friedrich  L.,  on  March  4,  191 5,  was  ordered  to  go  back  to 
the  baggage- train.  He  did  not  obey.  He  said  to  the  non- 
commissioned officer  who  then  came  to  him,  "I  am  not 
going;  you  have  nothing  to  say  anyhow,  you  ox-tender!" 
He  stood  with  his  hands  in  his  pockets,  and,  when  the  officer 
seized  him  angrily  by  the  collar,  L.  struck  the  officer's  face. 

He  stated  at  his  hearing  that  no  one  had  the  right  to  send 
him  back.  At  that  time  even  he  conveyed  the  impression  of 
being  not  quite  normal  and  was  let  off  with  his  arrest  only. 
Later  he  refused  again  to  go  on  guard  duty,  saying,  "You 
have  nothing  to  say  at  all.  Perhaps  you  will  find  out  that 
we  shall  meet  each  other  again  in  hell  tomorrow  morning." 
He  was  taken  before  the  physician,  who  considered  him 
mentally  inferior  and  not  entirely  appreciative  of  the  nature 
of  his  acts.  He  was  told  that  the  death  penalty  would  meet 
such  behavior,  whereupon  he  remarked,  "I  am  not  afraid  of 
the  death  penalty,"  staring  excitedly  at  the  officer  and  trem- 
bling throughout  his  body.  It  seems  that  he  had  already 
made  an  impression  of  mental  inferiority  in  the  troop,  and 
had  once  before  said  to  an  officer  who  wanted  to  send  him  to 
the  front,  that  he  would  not  go;  this  had  been  regarded  as 
almost  a  breach  of  discipline.  He  had  been  in  the  habit  of 
not  reacting  to  the  calls  of  his  superiors,  and  had  smiled  at 
their  reproaches.  He  seemed  to  hold  the  opinion  that  not 
even  a  company  commander  had  power  to  order  him  to  go 
back.  Examined  in  the  clinic  he  held  to  the  same  opinion, 
that  there  was  no  need  of  his  going  back;  that  they  took 
volunteers;  and  that  he  wanted  to  remain  at  the  front.  On 
the  day  of  the  deed,  he  had  drunk  a  rye  whiskey.  He  had 
shaken  off  the  non-commissioned  officer  because  the  leader 
had  seized  him  by  the  throat.  In  the  clinic  he  often  smiled 
and  wrinkled  his  forehead.  He  gave  evasive  and  inadequate 
answers.  Asked  about  oaths  and  perjury,  he  remarked, 
"I  prefer  to  remain  silent." 


HYPOPHRENOSES  59 

He  said  that  one  of  his  sisters  was  a  little  stupid.  Study 
of  his  previous  history  indicates  that  Friedrich  L.  had  for- 
merly been  a  quiet  and  steady  man,  although  he  often  had 
attacks  of  rage,  breaking  out  upon  sudden  excitements.  As 
to  his  capacity  in  school,  nothing  could  be  learned,  since  the 
Russians  had  taken  the  school  registers  away. 

The  analysis  of  this  case  seems  to  reduce  to  the  question 
of  feeblemindedness  and  schizophrenia,  unless  some  form  of 
inborn  qualitative  inferiority  of  mind  be  preferred  as  the 
diagnosis.  On  the  whole,  possibly,  the  diagnosis  of  feeble- 
mindedness seems  preferable.  The  entire  symptom  picture 
seems  to  relate  to  the  patient's  one  mental  attitude  about 
sticking  at  the  front,  ruat  coelum. 


60  HYPOPHRENOSES 

A  French  soldier  who  admu-ed  Germans. 


Case  48.     (Lautier,  1915.) 

A  man  with  the  extraordinary  first  name  of  Agapithe 
(Laurent  insists  on  the  frequency  of  strange  first  names  in 
degenerate  famiUes)  came  from  Val-de-Grace  to  Villejuif 
June  5,  1916,  with  the  diagnosis  of  mental  weakness,  interpre- 
tative ideas  of  persecution,  mental  excitement,  recrimination, 
logorrhoea,  and  a  tendency  to  revengeful  reactions. 

On  arrival  the  patient  said  he  must  be  in  an  insane  asylum 
because  he  heard  spiritiques  talking  together.  He,  however, 
was  "not  insane  "  and  began  expounding  his  plans  for  re- 
venge with  the  words  "Kill,"  "Cut-throat." 

This  man  had  been  placed  in  the  auxiliary  service  by  the 
Council,  called  to  the  colors  December  13,  1914,  and  finally 
sent  to  the  front  in  May,  191 5.  In  July  he  was  made  pris- 
oner in  a  brush.  He  said,  "I  cried  out,  'Comrades,  what 
difference  does  it  make  to  me  whether  I  am  German  or 
French?  My  ofhcers  are  imbeciles  that  drink  the  blood  of  us 
unlucky  ones! ' "  He  was  interned  in  some  camp  whose 
name  he  could  not  exactly  give  and  reported  that  the  Ger- 
mans were  very  gentle  with  him,  that  his  real  enemies  were 
the  French,  for  the  French  were  against  him  night  and  day. 
"As  a  matter  of  fact,  among  Germans  the  French  are  noth- 
ing but  cochons  malades.     The  Germans  are  fine  types." 

He  was  repatriated  in  May,  19 16.  He  kept  making  ver- 
bose and  neologistic  eulogia  of  the  Germans.  He  had  been 
a  farm  boy  in  Brittany,  where  he  had  had  headaches.  He 
had  been  at  Quimper  Asylum  in  1910.  In  fact,  he  said  his 
parents  had  tried  to  poison  him  and  to  have  him  assassinated; 
they  had  charged  him  with  setting  fire  to  their  house.  His 
mother  was  an  imbecile,  he  said,  who  believed  she  was  the 
Queen  of  France.  His  recriminations  did  not  stop  short  of 
himself.  He  had  been  accused  of  kissing  a  girl  and  stealing 
apples;  as  a  matter  of  fact  he  knew  what  to  do  with  girls. 

He  had  a  coarse  face  and  a  number  of  stigmata  besides  his 
name  Agapithe.     He  was  kept  at  Villejuif  as  an  imbecile. 


HYPOPHRENOSES  6 I 

Unfit  for  service :  Question  of  feeblemindedness. 


Case  49.     (Kastan,  January,  1916.) 

Walter  N.  was  declared  unfit  for  military  service  in  191 2, 
on  the  ground  of  mental  incapacity.  He  had  shown  this 
clearly  during  his  period  of  training.  He  committed  a  num- 
ber of  slight  offences  secretly,  but  not  so  secretly  but  that 
they  were  immediately  discovered  and  punishment  meted 
out  therefor.  He  could  do  nothing  without  aid.  It  appears 
that  his  mental  weakness  had  not  been  noticed  in  school,  but 
that  his  employers  had  thought  him  both  feebleminded  and 
irresponsible.  Nevertheless  he  always  executed  orders  prop- 
erly. While  in  hospital  in  1912,  he  had  occupied  himself 
very  little,  sitting  indifferently,  quiet  and  dreaming.  At  that 
time,  he  had  shown  poor  calculating  ability  and  decreased 
power  of  perception.  It  also  appears  that  he  did  not  grasp 
the  nature  of  simple  orders,  the  requisite  associations  being 
disturbed. 

Despite  this  history,  on  September  il,  1914,  he  found  him- 
self being  transported.  He  claimed  to  be  very  tired.  Upon 
reaching  the  city,  he  picked  up  a  large  stone  and  raised  his 
arm  as  if  to  strike  the  transport  leader.  While  N.  was  being 
bound  by  the  transport  leader  in  consequence,  he  kicked  at 
his  leader's  shins. 

In  the  clinic  he  resisted  examination,  moving  his  legs 
without  speaking,  staring  at  the  floor,  moaning  frequently, 
sitting  motionless  with  head  hanging,  answering  monoton- 
ously repeated  questions,  but  turning  his  head  at  a  loud 
noise.  He  felt  ill.  It  appeared  that  he  was  oriented  and 
that  his  knowledge  was  well  preserved  although  his  calcula- 
tion ability  was  poor. 

It  would  seem  that  psychiatric  examination,  possibly  with 
the  aid  of  psychological  work,  would  have  excluded  Walter 
N.  from  the  army. 


62  HYPOPHRENOSES 


Oniric    delirium  (Regis)    in    a    somewhat   feeble- 
minded Esthonian. 


Case  50.     (SouKHANOFF,  November,  191 5.) 

An  Esthonian,  21,  a  soldier  in  a  reserve  regiment,  came  to 
a  psychiatric  section  towards  the  close  of  19 14.  He  was 
negativistic,  mumbling,  restless,  fugacious;  later  more  tran- 
quil. One  day  he  entered  the  physician's  office,  walking  up 
and  down,  mute,  looking  at  articles  and  attempting  to  take 
them  away. 

February  21,  191 5,  he  was  evacuated  to  the  Notre  Dame 
Hospital  for  the  insane  at  Petrograd,  —  a  tall,  healthy, 
agitated-looking  youth  with  a  rapid  pulse.  He  explained  in 
poor  Russian  how  he  was  now  among  Germans  and  feared 
that  they  were  going  to  hurt  him.  At  first  in  the  hospital 
he  was  seclusive  and  morose.  March  9  he  became  excited, 
and  tried  to  break  through  the  door.  He  was  placed  in  the 
bath,  agitated  and  yelling.  An  Esthonian  interpreter  did 
not  quiet  him.  The  Germans  were  going  to  make  a  martyr 
of  him.  After  an  hour  of  this  he  grew  quieter,  and  next  day 
complained  only  of  head  weakness  and  malaise,  was  in  good 
humour,  smiling,  and  reading  an  Esthonian  paper,  and  well 
behaved  in  church,  though  tired  and  pale. 

He  now  got  better,  began  to  work  and  wrote  letters.  It 
seemed  as  if  he  had  waked  up  from  a  painful  dream.  He 
explained  how  he  though  he  had  been  in  captivity;  that 
he  was  going  to  be  hanged.  He  had  thought  that  the  Ger- 
mans could  talk  Russian.  He  had  had  hard  work  in  his 
regiment,  as  he  did  not  understand  Russian  and  had  never 
before  left  his  little  village  in  Livonia.  His  mental  disorder 
had  started  in  the  autumn,  but  all  that  was  now  like  a  dream. 
He  said  that  he  had  had  a  mental  disorder  of  short  duration 
following  some  bodily  disease,  at  the  age  of  thirteen.  Ac- 
cording to  Soukhanofif,  this  is  a  case  of  Meynert's  amentia, 
in  a  somewhat  feebleminded  person.  The  twilight  state 
might  well  receive  (according  to  Soukhanofif)  the  term  "oniric 
delirium  "  invented  by  Regis. 


HYPOPHRENOSES  63 


Shell-shock;  burial:    Incapacity  to  rationalize  the 
situation. 


Case  51.     (DuPRAT,  October,  1917.) 

A  soldier,  39,  a  herdsman,  was  shell-shocked  at  Hill  304 
May  23,  1916,  buried  twice,  slightly  wounded  in  right  eye, 
and  carried  unconscious  to  Bar-le-Duc.  He  was  then  forty 
days  in  a  semi-confusional  state  with  headaches  and  dreams 
of  the  Boches  wanting  to  behead  him.  Some  of  these  dreams 
came  in  the  waking  state,  in  which  state  he  could  recognize 
them  as  imaginary.  In  April,  191 7,  he  said  he  had  always 
been  afraid,  even  in  daytime,  that  he  would  be  hurt  and  had 
been  especially  troubled  by  the  fear  of  shells.  He  was  also 
bothered  by  nocturnal  enuresis  which  might  become  an  in- 
curable disease  and  bring  impairment  of  memory  and  atten- 
tion. Although  not  feebleminded  the  man  was  of  but  mod- 
erate intelligence,  and  his  emotions,  according  to  Duprat, 
were  such  as  to  defeat  any  complete  resolution  of  his  plight 
by  the  intellect. 

An  affective  complex,  passing  from  the  surprise  of  the  shell- 
shock  over  to  a  fright  based  on  clear  though  wrong  ideas  of 
what  might  happen  to  him,  had  left  him  without  sufficient 
power  of  autocritique. 


64  HYPOPHRENOSES 


Weakling,  twice  buried  by  shell  explosions  in  one 
day:  Change  of  character;  fear;  three  fugues  ("It 
is  stronger  than  I  am"). 


Case  52.     (Pactet  and  Bonhomme,  July,  191 7.) 

An  infantryman,  Class  of  191 3,  at  the  front  from  Sep- 
tember, 191 4,  had  a  somewhat  infantile  build  physically  but 
was  intellectually  of  average  powers,  having  been  a  type- 
setter (three  years  in  a  job).  However,  the  confined  life  had 
borne  hard  upon  him  and  his  father  put  him  on  a  farm.  He 
passed  through  his  military  service  successfully,  though  he 
was  given  two  weeks  in  the  guardhouse  for  overstaying 
Easter  leave.  He  was  suggestible  enough  at  this  time  to 
think  that  he  would  not  be  punished  very  severely,  since 
there  were  other  men  whose  leaves  did  not  expire  at  the  same 
time  as  his  own. 

He  was  burled  twice  in  the  same  morning,  March,  191 5, 
at  Bois  Le  Pretre,  spent  four  or  five  days  in  hospital,  and 
went  back  to  his  battalion.  But  now  there  was  a  change  in 
his  character.  Formerly  indifferent  to  danger,  he  was  now 
apprehensive  every  time  he  went  to  the  line  and  felt  an 
almost  irresistible  impulse  to  make  for  the  rear.  He  was 
condemned  to  five  years  in  prison,  June,  1915,  but  was 
finally  sent  back  to  the  front. 

However,  in  July  he  left  his  company  a  second  time  as  it 
was  going  into  the  trenches,  and  this  time  the  captain  simply 
asked  him  to  do  better.  A  third  fugue,  a  few  weeks  later, 
sent  him  back  to  court-martial,  and  thence  to  be  examined  by 
alienists.  He  was  perfectly  conscious  at  the  time  of  the  fugues 
and  understood  his  duties  and  possible  punishments.  All  he 
would  say  was,  "7/  is  stronger  than  I  am."  Fear  outweighed 
every  consideration  after  the  episode  of  the  shell  burials. 

The  man  may  be  regarded  as  a  hypobulic,  somewhat  feeble- 
minded person,  able  to  get  on  in  civil  life  but  thrown  out  of 
gear  by  war.  Of  course,  the  concept  of  fear  as  a  disease  can 
easily  be  overdone;  however,  here  was  a  case  in  which  three 
desertions  occurred;  the  third  after  severe  punishment.  In 
the  differential  diagnosis,  epilepsy,  alcoholism,  Impulsive 
poriomania,  must  be  considered,  as  well  as  feeblemindedness. 


III.   EPILEPTOSES 
(THE  EPILEPTIC   GROUP) 


Diagnosis  "  epilepsy  "  revised  to  neurosyphilis. 


Case  53.     (Hewat,  March,  191 7.) 

A  Scotch  soldier,  in  the  Royal  Navy,  43,  was  admitted  to 
the  Royal  Victoria  Hospital  at  Netley,  as  major  epilepsy. 
He  had  been  12  years  a  stoker,  and  16  years  before  admission 
had  suffered  from  syphilis,  a  chancre  locally  treated  with 
black  wash,  without  secondary  rash. 

After  leaving  the  Navy,  he  had  worked  in  a  fire-brigade 
and  as  dock  laborer.  He  had  been  very  alcoholic  when  funds 
permitted,  although  never  "primed."  His  first  convulsive 
seizures  came  at  40,  while  working  at  the  docks,  following  a 
night  on  which  he  had  drunk  a  bottle  of  whiskey.  He 
thought  he  had  been  about  half  an  hour  in  the  fit. 

He  joined  the  A.  S.  C,  January,  1915;  served  in  France; 
later  at  Salonica.  He  had  eight  convulsive  seizures,  some 
in  France,  and  others  at  Salonica,  always  after  much  rum. 

The  man  was  tall,  powerfully  built,  without  visceral  dis- 
ease, speech  defect,  or  other  symptoms  except  that  both 
pupils  showed  the  typical  Argyll- Robertson  phenomenon. 
The  deep  reflexes  of  arms  and  lower  legs  were  increased. 
The  superficial  reflexes  were  diminished,  and  the  Wasser- 
mann  reaction  strongly  positive.  A  seizure  was  observed 
by  Hewat  and  the  diagnosis  of  major  epilepsy  was  revised. 
The  diagnosis  of  cerebrospinal  syphilis,  non-paretic,  was  pre- 
ferred to  that  of  paresis  on  account  of  the  absence  of  all  the 
ordinary  symptons  of  paresis  and  of  tremor.  It  might  be 
asked  whether  these  fits  were  chiefly  alcoholic  in  origin. 
However,  the  patient  had  two  or  three  fits  while  in  hospital 
during  a  period  of  eight  teetotal  weeks.  Hewat  remarks 
that  the  case  suggests  that  the  serum  of  any  patient  develop- 
ing epileptiform  seizures  for  the  first  time  say  between  35 
and  50  years  of  age,  should  be  given  the  Wassermann  test. 

65 


66  EPILEPTOSES 


Syphilis  may  bring  out  epilepsy  in  a  subject  having 
taint. 


Case  54.     (BoNHOEFFER,  July,  1915.) 

A  man  of  35  in  the  Landwehr  acquired  syphilis  some  time 
in  the  summer  of  1914.  He  was  a  good  soldier,  passed 
through  several  clashes,  and  was  promoted  to   Unteroffizier. 

To  understand  what  followed  it  must  be  stated  that  he  had 
been  a  bed-wetter  to  11,  had  been  practically  a  teetotaler 
(Bonhoeffer's  point  is  perhaps  that  otherwise  epilepsy  might 
have  developed  sooner?),  and,  when  he  did  drink,  vomited 
almost  at  once,  and  had  amnesia  for  the  period  of  drunken- 
ness.    His  father  drank.     His  sister  had  fits  as  a  child. 

February,  191 5,  the  Unteroffizier  lost  appetite,  got  head- 
aches, and  went  to  hospital  for  a  time.  Upon  getting  better, 
he  was  sent  on  service  to  Berlin.  In  a  Berlin  hotel  he  had 
his  first  convulsions  and  unconsciousness,  biting  his  tongue. 
He  was  confused  for  several  days,  and,  when  he  had  become 
clear,  had  a  pronounced  retrograde  amnesia  together  with  a 
tendency  to  fabricate  a  filling  of  events  for  the  lost  period. 

This  retrograde  amnesia  is  uncommon  in  epilepsy  and 
suggests  organic  disease.  No  sign  of  such  was  found,  or 
signs  of  the  epileptic  make-up.  The  serum  W.  R.  was 
negative.  On  the  whole,  Bonhoeffer  regards  the  epilepsy  as 
"reactive  "  to  the  syphilis,  as  a  syphilogenic  epilepsy. 

Alcoholism  caused  amnesia  in  this  man  in  the  same  way  as 
the  syphilitic  epilepsy  now  did. 

Re  epilepsy  and  syphilis,  Bonhoeffer  states  that  he  has 
repeatedly  seen  syphilis  giving  no  other  symptoms  than  epi- 
lepsy develop  in  the  campaign.  At  the  same  time,  Bon- 
hoeffer does  not  find  that  the  incubation  period  in  paresis 
can  be  shortened  by  war  factors;  at  all  events,  by  the  ex- 
haustion factor  in  war  (see  Case  25).  It  might  be  questioned 
whether  the  above  case  (54)  was  not  psychogenic;  that  is, 
whether  the  syphilis  did  not  act  in  combination  with  being 
sent  to  Berlin  on  service  as  a  psychic  factor.  However,  this 
epilepsy  on  the  whole  seemed  not  psychogenic. 


EPILEPTOSES  67 


Syphilis  in  a  psychopathic  subject.     Convulsions 
5  days  after  Dixmude. 


Case  55.     (BoNHOEFFER,  July,  1915.) 

A  soldier  in  the  reserves,  23,  was,  subsequently  to  his 
being  brought  to  hospital,  described  by  his  wife  as  a  rather 
over-sensitive  fellow,  who  could  hardly  look  at  blood  and 
was  meticulous  about  the  household.  He  had  always  been 
subject  to  headaches,  especially  after  hard  work.  How- 
ever, he  had  passed  through  his  military  training  well  in 
1 9 10,  not  even  having  been  bestraft. 

He  began  service  in  October  and  fought  at  Dixmude  on 
the  19th.  On  the  24th  in  the  trench  and  while  being  carried 
back,  he  had  several  spells  of  pallor,  falling  stiff,  and  then 
having  convulsions.  Brought  finally  to  the  Charit6  in  Berlin, 
he  had  more  spells  of  sudden  pallor,  collapse  with  brief  con- 
vulsions, tossings  in  bed,  as  well  as  absences,  post-convulsive 
headaches,  and  mild  bad  humor. 

There  were  numerous  attacks  several  days  apart  in  the 
first  seven  weeks.  The  patient  was  not  of  an  "epileptic  " 
disposition,  though  readily  dissatisfied  and  headachey. 

The  serum  W.  R.  was  positive.  Treatment  by  mercurial 
inunctions.     No  further  convulsions.     Prognosis  doubtful. 

Re  epilepsy  and  the  war,  during  the  first  six  months 
Bonhoeffer  observed  33  cases  in  the  Charlt6  Clinic  in 
Berlin.  Twenty  of  these  33  cases,  unlike  Case  55,  had 
attacks  before  the  war,  although  ten  of  these  had  become 
epileptic  rather  late,  namely,  after  the  period  of  active  mili- 
tary service,  at  ages  from  22  to  27.  The  development  of 
epilepsy  like  Case  55's  is  not  without  frequent  precedent. 

Bonhoeffer  states  that  aside  from  epilepsy  directly  due  to 
brain  injury  by  shells,  there  has  been  no  certain  case  in  which 
we  have  the  right  to  regard  the  war  itself  as  the  total  cause 
of  the  epilepsy.  Some,  like  Case  55,  are  of  syphilitic  origin. 
No  subject  with  a  severe  long-standing  epilepsy  has  been 
able  to  get  into  the  field,  according  to  Bonhoeffer;  when 
they  do,  they  prove  constitutional  subjects. 


68  EPILEPTOSES 

An  epileptic  imbecile,  court-martialed. 


Case  56.     (Lautier,  191 6.) 

A  Belgian  soldier  was  condemned  by  court-martial  Feb- 
ruary 27,  1 91 5,  to  five  years  imprisonment  for  leaving  his 
post  in  the  presence  of  the  enemy.  It  seems  that  he  was 
mounting  guard  with  two  of  his  comrades  and  all  three  left 
to  eat  as  no  food  had  been  brought  to  them. 

A  physician  examined  the  Belgian  soldier  and  declared 
him  responsible,  although  a  little  sick.  All  three  were  con- 
demned to  imprisonment.  The  Belgian  attracted  attention 
in  prison  through  crises  of  anxiety  and  agitation;  he  had 
terrible  nightmares,  seeing  Germans  in  his  cell  and  hearing 
gunshots.  He  was  accordingly  sent  to  a  special  infirmary 
of  the  depot,  whence  July  24  to  Sainte-Anne,  July  26  to 
Villejuif.  He  talked  Flemish,  hardly  understanding  French, 
and  spoke  slowly  and  with  difficulty.  He  hardly  knew  how 
to  read  or  write.     He  had  been  a  truckman. 

At  18,  this  soldier,  according  to  his  own  account,  began  to 
have  nervous  crises  in  which  he  fell,  lost  consciousness,  bit 
his  tongue,  foamed  at  the  mouth  and  urinated  involuntarily. 
The  attacks  were  somewhat  rare.  His  father  sent  him  in 
1 9 10  to  Gheel  where  he  stayed  two  years.  Returning  home 
he  helped  his  father  in  the  trucking  work. 

When  the  Germans  came  the  family  fled  to  France  and, 
about  the  end  of  191 4,  he  was  put  into  the  military  service 
and  sent  to  the  front  after  a  very  short  period  of  instruction. 

The  man  had  followed  the  example  of  his  two  comrades 
without  taking  the  slightest  thought.  He  did  not  under- 
stand the  gravity  of  his  act.  He  was  not  remorseful,  re- 
gretful or  angry  against  his  judges.  He  was  well  oriented 
but  quite  indifferent.  He  was  a  tall,  intelligent  looking  man 
with  adherent  lobules,  slight  facial  asymmetry  and  evidence 
of  tongue  biting.  He  wrote  like  a  child  and  read  slowly, 
spelling  out  the  complicated  words.  He  was  employed  at 
various  manual  tasks  during  his  sojourn  at  the.  asylum  and 
had  no  epileptic  attack.  He  was  given  over  to  the  Belgian 
military  authorities  October  5,  191 5. 


EPILEPTOSES  69 

Seizures  in  a  feebleminded  subject  —  psychogenic 
components. 


Case  57.     (BoNHOEFFER,  July,  191 5.) 

A  2 1 -year  old  tailor,  unused  to  marching,  went  into  the 
field  in  August.  A  month  later,  after  a  period  of  long  stand- 
ing, he  was  nauseated  and  fell  in  a  faint.  Upon  waking,  his 
fingers  were  stiff  and  he  had  pains  in  his  legs.  He  got  better 
in  the  reserve  hospital  and  was  sent  back  to  the  line.  On  the 
way  he  had  a  similar  seizure,  with  nausea  and  fainting.  On 
the  way  back  to  Berlin,  he  had  a  seizure  in  the  railway  sta- 
tion, and  was  carried  to  the  Charite  Clinic.  At  the  clinic 
he  stated  that  he  could  feel  an  attack  come  on ;  that  he  first 
had  Angst  all  over  his  body,  and  that  it  was  hot  inside  of  his 
head.  Latterly  he  had  been  able  to  stop  an  attack  by 
clenching  his  teeth,  after  which  the  attack  would  not  proceed 
except  that  all  became  black  before  his  eyes. 

He  was  observed  for  four  weeks  but  no  seizure  appeared. 
He  was  somatically  negative;  his  Wassermann  reaction  was 
negative.  There  was  nothing  hysterical  about  his  make-up; 
he  was  somewhat  surly  and  of  low  mental  grade.  He  was 
unwilling  to  walk  alone  for  fear  of  attacks. 

As  to  the  heredity  of  this  soldier  nothing  is  known.  He 
had  been  an  illegitimate  child ;  he  was  a  sleep-walker  in  child- 
hood ;  he  had  sometimes  spoken  out  loudly  in  sleep  as  a  boy. 
At  school  he  had  been  somewhat  backward,  fought  readily 
with  his  mates,  and  often  complained  of  dizziness  and  head- 
aches. He  could  not  stand  smoking  or  drinking  well,  getting 
drunk  upon  two  glasses  of  beer.  He  had  not  held  positions 
well.  He  became  a  pionier  in  1914,  working  chiefly  as  a 
tailor. 

Early  in  his  time  as  a  soldier  he  had  obtained  an  ulcer 
of  the  glans,  which  had  been  excised  and  burned.  There 
had  been  no  secondary  symptoms. 

According  to  Bonhoeffer,  this  is  an  example  of  a  not 
infrequent  condition.  Although  the  attack  itself  and  the 
habitus  of  the  patient  did  not  look  hysterical,  the  manner  in 


70  EPILEPTOSES 

which  the  attacks  repeated  themselves  speaks  for  psychogenic 
components.  Just  as  genuine  hysterical  attacks  may  be 
looked  on  as  reactions  to  unpleasant  situations,  so  may  these 
attacks.  In  fact,  we  are  probably  dealing  with  an  hysterical 
fixation  of  the  symptoms  of  emotional  fright  like  those  in  the 
true  hysterias  following  shell  explosion.  A  great  many  of 
the  phenomena  of  Shell-shock,  to  use  the  English  phrase,  are 
not  in  and  of  themselves  of  a  psychogenic  nature,  but  they 
are,  according  to  Bonhoeffer,  psychogenically  liberated  under 
the  influence  of  unpleasant  ideas. 

Re  reactive  epilepsies,  Bonhoeffer  considers  that  there  is 
a  group  of  reactive  epilepsies  in  which  the  war  process  plays 
an  important  part.  The  prognosis  of  these  cases  ought  to 
be  relatively  favorable.  In  point  of  fact,  Case  57,  although 
a  feebleminded  subject,  seems  to  have  had  a  relatively  fav- 
orable prognosis:  at  all  events,  no  new  seizures  appeared 
under  prolonged  medical  observation.  These  reactive  seiz- 
ures may  occur  in  cases  with  a  labile  vasomotor  system. 
They  are,  according  to  Bonhoeffer,  aligned  rather  more 
with  hysteria  than  with  genuine  epilepsy.  Genuine  epilepsy 
has  not  been  developed  in  the  war  cases  observed  by  Bon- 
hoeffer except  where  an  endogenous  factor  was  clearly  in 
evidence;  or  else  where  there  was  the  requisite  antebellum 
soil  for  the  development  of  an  epilepsy.  In  short,  genuine 
epilepsies  developing  in  the  war  are  all,  according  to  Bon- 
hoeffer, predispositional.  The  antebellum  soil  was  clearly 
in  evidence  in  Case  57.  Even  before  the  war,  according  to 
Bonhoeffer,  many  German  soldiers  during  the  period  of  mili- 
tary service  gave  evidence  of  their  epileptic  soil  by  sundry 
suspicious  phenomena.  Among  these  were  fainting  spells 
during  hard  drilling  and  other  exercises,  spells  of  enuresis, 
abnormally  deep  sleep,  and  even  phenomena  of  somnambu- 
lism. One  of  the  Bonhoeffer  epileptics  had  been  released 
during  his  reservist  practice  as  unfit  for  military  service, 
and  had  only  been  put  into  the  line  at  his  own  urgent  request 
at  the  outbreak  of  the  war.  Three  volunteers  concealed 
their  epileptic  history.  One  man,  who  had  had  merely  petit 
mal  attacks  before  the  war,  regarded  them  as  of  little  con- 
sequence, entered  the  ser\ace,  and  developed  epilepsy. 


EPILEPTOSES  71 


Responsibility  of  a  drunken  epileptic. 


Case  58.     (JuQUELiER,  March,  191 7.) 

The  question  of  responsibihty  arose  in  the  case  of  a  soldier 
who  left  his  camp  the  morning  of  October  23,  1916,  and  went 
to  a  neighboring  place,  where  he  drank,  with  four  others, 
two  quarts  of  wine.  At  about  three  o'clock  in  the  afternoon, 
his  captain  met  him  on  the  street,  lost,  and  looking  drunk. 
He  told  him  that  he  would  send  him  to  the  trenches  in  the 
evening.  The  man  lay  down  and  went  to  sleep.  At  about 
six  o'clock,  it  was  found  that  he  could  not  put  on  his  equip- 
ment alone,  and  in  fact  threatened  the  other  men  with  his 
bayonet,  and  then  went  to  sleep.  He  woke  up  and  explained 
that  he  had  had  one  of  his  nervous  crises.  He  remembered 
the  matter  of  the  bayonet  but  had  forgotten  everything  else 
about  the  struggle. 

This  soldier  was  29  years  old,  the  son  of  an  alcoholic,  and 
the  ninth  child  of  a  mother  who  died  shortly  after  her  tenth 
pregnancy.  He  had  had  measles  and  bronchitis  as  a  child, 
and  in  childhood  had  had  bad  dreams;  at  the  age  of  ten  he 
had  swooning  spells.  He  became  a  quarryman  and  a  habit- 
ual drinker,  subject  to  dyspepsia,  nightmares,  and  nocturnal 
cramps.  There  had  never  been  any  crises,  however,  up  to 
wartime. 

January,  1916,  when  a  shell  burst  near  him,  the  first  sharply- 
defined  epileptoid  crisis  came,  and  was  followed  by  a  number 
of  others,  either  on  leave  or  on  service,  March  8,  June  2,  and 
July  13.  These  attacks  showed  a  sudden  fall  without  warn- 
ing, loss  of  consciousness,  convulsions,  tongue  biting,  incon- 
tinence of  urine,  a  period  of  more  or  less  coordinate  agitation 
at  the  time  consciousness  was  reappearing,  sometimes  a 
fugue,  and  often  amnesia  for  the  whole.  He  had  a  scar  on 
the  left  border  of  the  tongue. 

Should  this  epilepsy  be  regarded  as  entailing  irrespon- 
sibility? He  left  camp  before  the  crisis,  accordingly  in  a 
period  when  he  was  in  full  possession  of  consciousness  and 
will,  and  he  had  gotten  into  an  irregular  situation  by  drunk- 


72  EPILEPTOSES 

enness  before  his  epileptic  crisis  started  in.  His  struggle 
with  his  comrades,  however,  appears  to  be  a  portion  of  a 
post-critical  dazed  state.  The  medicolegal  decision,  therefore, 
was  that  he  was  guilty  of  leaving  his  command  but  not  of 
the  other  misdemeanor.  Considering  the  general  nature  of 
epilepsy,  the  responsibility  of  this  man  for  the  whole  adven- 
ture is  rather  slight.  The  Council,  however,  comdemned 
the  man  to  five  years  of  labor,  without  admitting  that  the 
crisis  following  so  soon  the  actual  misdemeanor  should  argue 
a  diminution  of  responsibility. 

Re  epilepsy  in  the  army,  Lepine  notes  the  serious  theo- 
retical and  practical  problems  to  which  it  gives  rise.  In 
the  first  place,  epilepsy  occurs  in  the  army  more  frequently 
than  in  the  same  number  of  men  in  civilian  life.  Conse- 
quently, the  diagnosis  as  to  the  really  epileptic  nature  of  the 
attacks  observed  is  not  too  easy.  Again,  the  situation  ajffords 
much  opportunity  for  simulation  (see,  for  example,  the  case 
of  sham  fits  (Case  78,  Hurst),  and  the  case  of  epileptoid  at- 
tacks controllable  by  the  will  (Case  79  of  Russell).  Wounds 
may  produce  it,  and  even  wounds  which  do  not  afifect  the 
brain;  besides  which,  a  variety  of  war  conditions,  short  of 
trauma,  may  produce  it.  When  the  ordinary  impulsiveness 
of  the  epileptic  turns  into  automatism  and  to  epileptic  equiv- 
alents {Stats  seconds),  much  of  medicolegal  interest  may 
happen.  Case  58  was  just  short  of  a  murderer.  Cases  of 
actual  murder  in  epileptic  equivalents  have  been  known  under 
military  conditions.  Fugues  with  amnesia  for  the  phenomena 
(which  look  to  the  military  man  like  intentional  desertions) 
form  another  group  of  epileptic  events;  but  aside  from  the 
manias  and  the  fugues,  there  are  still  more  dubious  epilep- 
toid phenomena  of  a  delusional  and  confusional  nature,  such 
that  the  proof  of  epilepsy  comes  only  afterward,  when  frank 
convulsions  supervene.  Re  fugues  and  desertion  (the  most 
frequent  of  military  delinquencies  according  to  Regis),  we 
may  think  of  the  fugue  reaction,  according  to  L6pine,  as  a 
natural  reaction  on  the  part  of  both  the  true  delinquent  and 
the  mentally  sick  subject.  The  loss  of  liberty,  alcohol, 
fatigue,  minor  phenomena  of  commotio  cerebri,  may  lead  to 
states  of  mental  depression  that  favor  the  fugue.     It  is  an 


EPILEPTOSES  73 

affair  of  the  greatest  delicacy  for  the  expert  to  build  up 
again  the  exact  plight  of  the  soldier  at  the  time  of  his  deser- 
tion. Special  inquiry  must  be  made  of  the  man's  mates. 
Only  in  this  way  can  the  wheat  be  separated  from  the  chaff 
and  punishment  allotted  to  those  only  who  deserve  it. 

According  to  Lepine,  there  are  fewer  guilty  fugitives  than 
there  are  innocent  ones,  or  at  least  partially  innocent  ones. 
In  the  decision,  one  takes  account  of  the  duration,  the  course, 
and  the  peculiarities  in  the  termination  of  the  suspicious 
flight.  According  to  the  military  code,  there  are  cases  like 
Case  58  in  which  the  fugue  itself  was  carried  out  in  an  un- 
conscious state,  and  yet  in  which  the  martial  responsibility 
of  the  man  was  absolute.  Drunkenness  is  no  excuse  for  the 
fugue,  even  if  the  latter  is  automatically  carried  out.  Of 
course,  the  paretic  is  not  responsible  for  his  fugue  any  more 
than  the  organic  dement,  the  delirious  uremic,  or  the  chronic 
alcoholic,  who  is  already  severely  demented.  For  a  case  of 
this  sort,  see  Case  i  (Briand) 

In  the  differential  diagnosis,  we  must  also  consider  that 
fugues  may  be  carried  out  in  confused  states  as  well  as  at 
times  in  various  paranoid  states,  and  even  in  melancholia. 


74  EPILEPTOSES 

A  disciplinary  case :  Epilepsy. 


Case  59.     (Pellacani,  March,  191 7.) 

A  Milanese  workman,  28,  was  exposed  to  the  sun  on  sen- 
try-go and  had  an  attack  of  convulsions,  on  awaking  from 
which  he  found  himself  in  hospital.  He  always  had  attacks 
in  reaction  to  emotion.  One  day,  in  a  quarrel  provoked  by 
jealousy  concerning  a  prostitute,  he  apparently  lost  his  mind, 
whipped  out  a  hunting-knife,  and  wounded  a  comrade. 
Thereafter  he  lay  unconscious  until  the  next  day.  The 
court-martial  decided  that  he  was  not  fully  responsible. 

Eventually,  he  was  sent  from  the  front  for  having  insulted 
and  struck  a  superior  officer.  The  report  read  also  that  he 
was  a  prey  to  delirium  and  had  frothed  at  the  mouth.  In 
the  interior  he  had  convulsive  attacks,  with  falling  and  loss 
of  consciousness.  He  told  of  arguing  with  a  sergeant  about 
a  bicycle,  of  seeing  darkness  before  his  eyes  like  a  veil,  and  of 
subsequent  amnesia.  In  hospital  he  had  intense  headaches 
at  times,  with  spells  of  sullenness,  hostility,  and  complaints 
concerning  nurses  and  attendants  and  other  patients.  At 
other  times,  he  was  quiet  and  comfortable.  One  day  he 
went  into  an  excitement  and  wept,  asking  to  be  sent  back  to 
the  army,  striking  the  table  with  his  fist  and  head.  He  then 
screamed,  flew  into  a  passion,  and  fell  to  the  ground  in  semi- 
stupor,  shaking  his  body  and  trying  to  kick  and  knock  away 
those  who  intervened.  He  was  placed  in  bed  but  remained 
agitated  and  unconscious,  with  anesthesia  and  frothing  at  the 
mouth.  The  abdominal  and  cremaster  reflexes  were  absent 
in  this  attack,  and  the  pupils  were  rigid  and  myotic.  The 
pulse  was  rapid  and  the  blood  pressure  high.  Afterwards 
he  was  sleepy,  stupid  and  weary,  and  showed  fine  rapid 
tremors  of  hands,  tongue,  and  eyelids.  The  abdominal  re- 
flexes now  returned  in  excess,  and  a  marked  dermatographia 
developed. 

Upon  investigation,  it  was  found  that  the  patient's  father 
was  also  an  epileptic  and  was  alcoholic;  that  one  paternal 
uncle  had  died  in  an  asylum;  another  of  apoplexy;   that  two 


EPILEPTOSES  75 

maternal  uncles  were  chronic  alcoholics  (one  in  an  institu- 
tion) ;  that  an  alcoholic  brother  had  been  six  times  convicted 
of  assault  and  battery;  that  a  sister  had  howling,  crying,  and 
hair-pulling  spells,  throwing  herself  to  the  ground.  The 
patient  himself  had  had  an  early  Bright's  disease  and  had 
always  been  an  undiscipHned,  excitable,  and  impulsive  boy, 
sometimes  kept  out  of  school.  His  first  conviction  was  at 
1 8,  for  assaulting  a  policeman,  and  he  had  been  arrested 
four  further  times  for  assault  and  battery.  He  stated  that 
his  convulsive  attacks  with  the  veil  before  the  eyes  came  on 
when  he  was  irritated  or  had  taken  cold,  or  had  drunk  to 
excess,  or  had  over-exerted  himself.  He  said  he  suffered 
from  intense  headache,  weariness,  and  sleepiness  after  an 
attack.  He  always  bit  his  tongue  at  the  same  period.  Irrita- 
tion and  exertion  sometimes  caused  attacks  of  dizziness  and 
vertigo  without  unconsciousness.  Alcoholism;  ulcer  in  an 
inguinal  gland.  He  had  been  confined  in  an  asylum  40  days 
for  epilepsy,  attacks  of  which  had  become  more  frequent 
after  he  had  heard  of  his  father's  death. 

Re  violence  and  epilepsy,  Lepine  remarks  that  a  pure 
epilepsy  unclouded  by  alcoholism  may  occasionally  give  rise 
to  acts  of  extreme  violence,  but  these  pure  epileptic  violences 
are  infinitely  rarer  than  the  alcoholic  ones.  The  Milanese 
was  in  point  of  fact  alcoholic,  and  in  his  ancestry  were  a 
number  of  alcoholics  as  well  as  epileptics.  According  to 
L6pine,  when  subjects  are  "out  for  blood,"  they  are  almost 
always  either,  like  this  Milanese,  hereditary  alcoholics,  or 
else  strongly  predisposed  subjects,  or  even  the  offspring  of 
the  insane. 


76  EPILEPTOSES 

A  disciplinary  case :  Epileptic  attacks  with  amnesia. 


Case  60.     (Pellacani,  March,  1917.) 

A  Veronese,  23,  quarrelled  with  his  comrades,  and  one  day 
wounded  one.  Another  time,  when  reproved  by  a  superior, 
he  struck  him  with  a  shoe;  and  at  still  another  time,  hurled 
himself  upon  his  superior  officer  eind  bore  him  to  the  ground. 
Yet  he  seemed  to  have  a  perfect  amnesia  for  all  these  violent 
acts.  At  other  times,  he  had  convulsive  attacks  with  a 
mental  state  which  seemed  to  combine  anger  and  depression, 
after  which  he  would  fall  to  the  ground,  lose  consciousness, 
go  into  clonic  spasms,  spit  bloody  saliva,  and  cause  wounds 
and  abrasions  upon  his  body.  Once,  after  such  an  attack, 
he  passed  into  a  brief  excited  spell.  Finally  he  was  so  in- 
subordinate and  violent  to  superior  officers,  that  he  was 
brought  under  hospital  observ^ation,  having  been  excited  and 
confused  for  a  day. 

Next  day  he  was  lucid,  oriented,  and  tranquil;  entirely 
amnestic  for  what  happened  the  day  before,  though  his  acts 
were  sufficiently  unusual.  He  had  threatened  his  superior 
officer  and  been  reproved  and  sent  to  prison  to  think  it  over. 
In  prison  he  had  suddenly  thrown  himself  against  another 
innocent  person  and  clutched  him  tightly  about  the  neck. 
He  threw  another  violently  to  the  ground  and  then  ran  to 
help  the  previous  victim!  Bound  fast,  he  had  succeeded  in 
freeing  himself  and  thrown  himself  furiously  against  the  prison 
door,  whereupon  he  had  fallen  to  the  ground  in  an  epileptic 
fit.  He  had  tachycardia  (120)  and  a  generalized .  hypalgesia. 
The  vasomotor  reactions  were  excessive. 

Upon  investigation  it  proved  that  his  mother  had  been 
subnormal  and  that  the  patient  had  been  constitutionally 
excitable  and  unstable,  given  to  attacks  of  anger  and  Im- 
pulsiveness from  youth  up.  In  fact,  he  had  been  in  prison 
several  times  for  violence.  He  described  himself  In  his  rest- 
less spells  as  feeling  a  trembling  all  over  his  body  as  If  his 
blood  were  boiling  in  his  heart  and  his  head,  whereupon  he 
would  lose  knowledge  of  what  he  was  doing.     He  had  been  a 


EPILEPTOSES  77 

quarrelsome  boy,  pursuing  his  mates  with  knives  and  stones. 
Once,  after  arguing  with  a  car  conductor,  he  had  broken  the 
car  windows,  turned  everything  upside-down,  and  thrown  the 
conductor  into  the  street. 

Case  60  is  clearly  in  the  same  group  as  Case  59.  The 
Veronese  falls  into  the  same  frame  with  the  Milanese  except 
that  he  appears  not  to  have  been  alcoholic.  The  insub- 
ordinations of  the  Veronese  were  apparently  carried  out  in 
a  state  of  unconsciousness.  The  majority  of  insubordinates 
appear  not  to  be  epileptics.  Some  authors  have  called  atten- 
tion to  pathological  politeness  as  an  occasional  symptom  in 
epilepsy.  Perhaps  the  majority  of  insubordinate  cases  are 
feebleminded  or  schizophrenic. 


78  EPILEPTOSES 

Desertion  in  epileptic  fugue. 


Case  6i.     (\'erger,  February,  1916.) 

A  blacksmith  from  the  Rochefort  Arsenal,  27  (nothing 
known  as  to  grandparents;  father,  now  in  the  fifties,  for  30 
years  In  an  asylum  with  frequent  attacks  of  furor;  mother, 
45,  well  and  apparently  well-balanced;  brother  with  the 
colors,  wounded  and  decorated  with  the  military  medal;  a 
cousln-german,  who  has  had  a  typical  epilepsy  —  in  the 
patient  himself  enuresis  up  to  13  or  14,  later,  less  frequently; 
apparently  no  tongue-blting;  no  information  as  to  infec- 
tious diseases;  graduate  from  primary  school,  apprenticed 
to  a  blacksmith;  an  unskilful  worker;  never  able  to  rise  to 
the  level  of  a  frappeur),  in  1909  had  passed  the  board  of 
review  and  been  put  in  the  sixth  division  of  the  line.  Ante- 
bellum there  was  a  history  that  one  night  at  supper,  he  had 
slipped  away  from  quarters  and  gone  30  kilometres,  home. 
His  astonished  mother  sent  him  back  to  the  military  post  by 
railway. 

Upon  the  night  of  Alay  26-27,  1915,  this  soldier  found 
himself  In  the  position  of  a  sentry,  opposite  the  enem^'.  He 
told  his  comrade  that  he  had  to  go  away  for  a  time,  leaned 
his  gun  against  a  tree,  disappeared,  and  did  not  return.  It 
was  then  one  o'clock  In  the  morning.  At  six  o'clock,  he  was 
found  two  kilometres  away  from  the  lines.  In  a  village.  He 
was  in  front  of  a  barn  where  his  company  had  been  quartered 
before  taking  possession  of  the  advanced  posts. 

He  was  brought  up  before  the  military  authorities;  but 
upon  stating  that  in  civil  life  he  had  wandered  off  several 
times  without  knowing  where  he  was  going,  he  was  submitted 
to  neurological  examination.  There  was  available  a  letter 
from  his  family  physician  relative  to  his  antebellum  military 
service.  It  appeared  that  he  had  committed  a  number  of 
breaches  of  discipline,  and  that  he  was  regarded  by  the  physi- 
cians as  a  desequilibre.  He  had  lived  with  his  mother  a  very 
quiet  and  good  life;  there  was  no  history  of  sexual  irregu- 
larity, and  no  history  of  illness  except  a  slight  catarrhal 
jaundice.     He  had  frequently  suffered  from  headaches ;  there 


EPILEPTOSES  79 

had  been  slight  attacks  of  vertigo  of  very  brief  duration.  He 
had  never  fallen  in  these  fits.  From  his  story  it  was  elicited 
that  he  had  had  absences;  his  comrades  had  noticed  that  he 
sometimes  stopped  stock-still  with  vague  eyes,  then  shortly 
regained  his  wits  and  continued  upon  his  task.  Sometimes 
he  would  not  work  without  being  able  to  explain  why  he 
went  away.  He  would  go  off  for  a  period  and,  upon  coming 
to,  discover  that  he  had  not  eaten  his  meals.  There  were 
never,  however,  any  convulsive  crises  by  day  or  night.  He 
sometimes  felt  sick,  and  although  there  was  no  medical 
treatment,  from  time  to  time  he  took  bromides  upon  his  own 
authority,  saying  he  had  been  ordered  to  do  so  by  his  father. 
Although  habitually  of  a  gentle  demeanor,  nevertheless  he 
was  subject  to  excessive  anger  upon  slight  occasion. 

During  the  mobilizing  and  first  months  of  the  war,  both 
in  quarters  and  at  the  front,  however,  his  conduct  had  been 
that  of  a  good  soldier.  Suddenly,  about  March  or  April, 
1 91 5,  the  nocturnal  enuresis  began  to  be  frequent  again, 
occurring  twice  or  three  times  a  week;  but  the  patient  hid 
this  misfortune  as  far  as  possible  from  his  comrades.  The 
captain  thought  he  looked  tired  and  depressed  sometimes. 
Upon  the  days  following  the  nights  with  enuresis,  there  was 
intense  headache  and  marked  moral  and  physical  depression. 
There  was  no  proof  of  nocturnal  convulsions,  and  it  is  very 
problematical  whether  there  was  tongue-biting. 

Another  odd  feature  was  that  the  patient,  who  had  been 
sober  in  civil  life,  had  become  intoxicated  several  times  after 
going  into  the  army.  Physically,  he  was  of  low  stature,  but 
otherwise  well  built.  Neurologically,  he  was  entirely  nega- 
tive. There  was  no  sign  of  venereal  disease.  There  were  a 
few  stigmata  of  degeneration;  for  instance,  there  was  very 
little  hair  upon  the  face,  the  ears  were  unequal  in  size,  and 
the  teeth  were  somewhat  anomalously  set.  Mentally,  he 
was  below  par;  for  instance,  he  could  not  add  mentally  two 
numbers  of  two  digits. 

As  to  his  desertion,  the  patient  says  he  does  not  know 
what  he  did;  that  he  learned  of  his  act  only  from  his  com- 
rades in  the  morning;  that  he  remembered  having  left  his 
duty  pour  alter  satisfaire  un  hesoin. 


80  EPILEPTOSES 


A  Specialist  in  escapes  (epileptic  fugues). 


Case  62.     (LoGRE,  March,  1917.) 

An  epileptic  fugue  with  recidivism  is  described  by  Logre. 
He  described  himself  as  a  specialist  in  escapes.  As  a  school- 
boy, he  had  practised  escapes  and  run  away  without  purpose, 
and  without  remembering  fully  what  he  had  done.  His 
father  would  bring  him  back  to  school.  At  first  they  had 
punished  him  and  then  would  pardon  him.  These  escapades 
in  his  work  as  a  shoemaker  caused  him  to  lose  various  places, 
but  he  had  been  kept  by  one  employer  for  a  long  time  never- 
theless. From  II  years  on,  this  patient  had  never  ceased 
living  either  in  foreign  parts  or  in  prison. 

The  fugues  on  military  service  began  to  multiply.  The 
miHtary  chiefs  did  not  abide  the  escapades  like  the  school- 
master or  the  employer.  Every  punishment  he  received  had 
to  do  with  some  fugue.  Three  times  he  gave  himself  up  to 
the  military  authorities.  Three  times  after  a  few  more  days' 
service  or  a  week  in  prison,  he  left  the  barracks  or  escaped. 
There  had  never  been  any  appeal  throughout  this  history  to 
an  alienist.  On  the  declaration  of  war,  he  had  returned  to 
Belgium  and  was  put  into  the  army;  whereupon  in  January, 
he  carried  out  a  fugue  of  a  few  hours  which  was  rewarded 
with  eight  days  in  prison.  There  was  a  five-days  fugue  in 
July,  whereupon  he  was  taken  before  the  council. 

Upon  investigation,  these  fugues  seemed  to  have  the 
classical  features  of  epileptic  fugues.  They  were  sudden, 
unconscious,  blindly  automatic,  almost  completely  forgotten 
afterwards  and  of  a  stereotyped  and  recidivistic  nature. 
Most  of  the  fugues  had  been  preceded  by  a  slight  excess  in 
drinking.  An  investigation  was  made  to  see  if  there  were 
any  convulsive  antecedents;  none  were  found.  This  mental 
epilepsy,  then,  it  was  thought,  must  be  an  isolated  symptom, 
free  from  every  motor  symptom.  But  his  mother  and  one 
of  his  brothers  had  also  shown  a  number  of  attacks  of  some 
sort  of  epilepsy.  In  all  three  cases  there  was  impulsivity, 
unconsciousness,  absurdity,  recidivism,  and  refractoriness  to 


EPILEPTOSES  8 1 

treatment.  On  these  grounds  the  fugue  was  regarded  as 
pathological  and  as  epileptic  probably.  The  patient  him- 
self thought  that  these  coups-de-tete  and  this  mania  for  run- 
ning away  without  knowing  where,  made  really  a  very  ugly 
fault,  particularly  in  a  soldier. 

Re  such  specialists  in  escapes  as  Case  62,  Lepine  speaks 
of  a  type  of  military  delinquent  which  he  calls  Ceux  qui 
sautent  le  mur.  Some  of  the  fugue  subjects,  as  well  as  other 
types  of  imbalance  can  apparently  be  held  by  no  possible 
kind  or  degree  of  discipline.  They  jump  any  guardhouse 
or  any  other  form  of  imprisonment  through  what  amounts 
to  a  wild  instinct  for  liberty.  In  some  cases,  this  instinct 
appears  in  a  relatively  pure  form;  that  is,  without  any 
combined  tendency  to  dipsomania  and  without  any  sexual 
factor.  Some  of  them  are,  in  fact,  very  good  soldiers,  espe- 
cially in  shock  troops.  They,  in  fact,  belong  to  what  one 
might  call  the  good  element  among  delinquents.  In  the 
French  Army  some  of  them  have  been  old  legionaries  and 
have  even  been,  as  in  Case  62,  previously  condemned  for 
desertion.  They  form  a  curious  minority  among  the  wall 
jumpers.  Wall- jumping  makes,  so  to  say,  the  entire  patho- 
logical phenomenon,  and  the  recidivism  is  a  part  of  the 
disease. 


82  EPILEPTOSES 

A  disciplinary  case :  Epilepsy  and  other  factors. 


Case  63.     (CoNsiGLio,  191 7.) 

An  Italian  private  in  the  artillery  (father  dead  of  general 
paresis)  had  been  a  victim  of  infantile  convulsions  and  of 
convulsions  with  loss  of  consciousness  up  to  18  (convulsions 
with  shouts  and  violence  in  the  streets  of  Rome;  had  to  be 
put  in  a  straight- jacket  at  the  municipal  hospital). 

He  developed  more  convulsions  during  antisyphilitic  treat- 
ment in  the  military  hospital.  He  was  a  very  poor  soldier, 
of  the  rough  and  violent  sort,  and  after  eight  months  of  ser- 
vice had  to  be  assigned  to  a  special  disciplinary  company, 
with  which  he  remained  for  fifteen  months.  Here  also  he 
was  punished  frequently,  and  was  given  a  period  of  four 
months'  imprisonment  for  refusal  to  obey  the  ofhcers.  Then 
for  a  period  of  several  years  he  had  no  convulsions  whatever. 

During  the  war  he  was  given  to  alcoholism,  and  one  day  in 
June,  1916,  he  struck  an  ofhcer  and  ran  away  to  arm  himself. 
He  was  at  this  time  observed  by  psychiatrists  and  declared 
sane.  He  was  regarded  as  an  emotional  and  alcoholic  epi- 
leptic but  not  as  neurotic  or  psychopathic.  He  was  again 
placed  in  a  special  disciplinary  corps. 

Re  the  convulsions  which  this  Italian  developed  during 
antisyphilitic  treatment,  it  would  be  interesting  to  know 
whether  intravenous  injections  were  used.  In  case  they  were 
used,  one  might  compare  the  case  of  this  Italian  with  Bon- 
hoeffer's  volunteer  who  developed  epileptic  convulsions  after 
antityphoid  inoculation. 

Re  the  insubordination  and  violence  of  this  Italian,  com- 
pare remarks  of  Lepine  noted  under  Cases  59  and  60.  Re 
the  "other  factors,"  compare  remarks  of  Bonhoeffer  noted 
under  Case  57. 


EPILEPTOSES  8^ 


An  epileptic  goes  through  Mons  and  two  years  fight- 
ing without  symptoms.  Then  strange  conduct  with 
amnesia. 


Case  64.     (Hurst,  March,  191 7.) 

A  private,  26,  epileptic  from  11  to  18  (mother  also  epilep- 
tic) entered  the  army  at  20,  attempted  to  commit  suicide  in 
19 1 2  (amnestic  for  this  attempt),  and  went  to  France  with 
the  expeditionary  force  in  August,  1914.  The  retreat  from 
Mons  and  further  fighting  caused  no  recurrence  of  the  symp- 
toms. September,  1916,  he  was  in  fact  put  in  charge  of 
eight  men  doing  guard  duty.  At  this  time  he  was  able  to  get 
to  bed  only  every  other  night.  The  charge  of  the  telephone 
worried  him,  as  he  had  never  before  been  made  to  assume 
responsibility.  After  two  months  of  this,  he  was  found  one 
night  arresting  civilians  without  cause  and  driving  them  be- 
fore him  with  fixed  bayonet.  He  was  let  off  court-martial  on 
the  medical  evidence,  and  at  hospital  remained  confused  and 
suspicious.  November  16,  he  was  seen  by  a  medical  ofhcer 
in  a  typical  attack  of  petit  mal.  Of  all  this,  on  reaching 
England  December  19,  he  had  no  recollection,  and  was  keen 
to  return  to  duty. 

Re  the  remarkable  delay  in  the  return  of  epilepsy  to  this 
soldier  of  Mons,  Bonhoeffer  remarks  that  one  of  the  epi- 
leptics observed  by  him  at  the  Charite  Clinic  had  passed 
through  nine  battles,  and  another  through  18  battles  before 
the  first  attack  of  epilepsy.  Bonhoeffer  regarded  the  stren- 
uous marching  as  a  liberating  factor  of  epilepsy  in  five  cases, 
actual  fighting  in  seven  cases,  shell  explosions  in  two  cases, 
and  bullet  wounds  in  three. 

Re  the  apparently  psychogenic  factor  in  Hurst's  case 
(epilepsy  coming  on  after  assumption  of  too  great  responsi- 
bilities), compare  remarks  of  Bonhoeffer  under  Case  57  con- 
cerning psychogenic  factors.  Sir  George  Savage  has  called 
attention  to  a  form  of  functional  epilepsy  following  shock  or 
injury,  in  which  recovery  occurs  after  removal  from  the  strain, 
but  in  which  there  is  a  relapse  if  the  men  go  back  to  duty. 


84  EPILEPTOSES 

Therapeutic  (antityphoid  inoculation)  epilepsy. 


Case  65.     (BoNHOEFFER,  July,  1915.) 

A  volunteer  without  psychopathic  signs  except  a  slight 
stuttering,  and  without  psychopathic  history  of  any  sort, 
went  into  service  at  17.  After  he  had  been  a  short  time  in 
the  field,  a  shell  fragment  injured  him  in  the  upper  part  of  the 
thigh.  He  lay  up  in  hospital  four  weeks.  He  then  spent 
four  weeks  in  the  reserve. 

He  was  then  given  antityphoid  inoculation,  and  a  half 
hour  afterward  had  epileptic  convulsions.  These  appeared 
four  times  more  during  the  next  fortnight,  as  a  rule  followed 
by  a  delirious  excitement.  No  fever  was  reported.  After 
the  fourth  attack,  he  was  transferred  to  the  Charite  Clinic. 

At  the  clinic  there  were  no  attacks,  and  there  was  nothing 
epileptic  to  discern  in  the  make-up  of  the  patient.  His 
nervous  system  was  normal  to  examination.  There  was, 
however,  one  fact  in  the  family  history  of  note,  namely, 
that  an  older  brother  of  the  patient,  20  years  of  age,  sufifered 
from  convulsions. 

What  is  the  relation  of  the  antityphoid  inoculation  to  the 
epilepsy?  According  to  Bonhoeffer,  we  must  not  forget  the 
family  history  even  if  we  regard  the  inoculation  as  the  lib- 
erating factor.  Curiously  enough,  the  shell  injury  did  not 
itself  serve  apparently  to  bring  out  the  epilepsy.  Bonhoeffer 
has  seen  three  other  instances  of  epileptic  attacks  or  epilep- 
toid  phenomena  following  antityphoid  inoculation.  How- 
ever, in  the  hundreds  of  thousands  of  inoculations,  it  is  not 
to  be  wondered  at  perhaps  that  there  should  be  a  number 
of  instances  of  epileptic  attacks.  One  was  a  man  with 
severe  epileptic  taint ;  in  the  others,  there  was  a  question  of 
pathological  intoxication. 

Re  antityphoid  inoculations,  a  French  observer  —  Paris 
—  remarks  that  these  inoculations  may  occasionally  start 
up  the  symptoms  of  general  paresis.  Compare  in  this  con- 
nection also  Case  63,  in  which  a  syphilitic  developed  convul- 
sions during  antisyphilitic  treatment.  The  psychogenic 
factor  of  intravenous  injection  itself,  with  its  possible  efTect 


EPILEPTOSES  85 

upon  glands  of  internal  secretion,  can  hardly  be  distinguished 
from  purely  serological  effects.  Paris  goes  so  far  as  to  state 
that  he  regards  it  as  imprudent  to  vaccinate  a  syphilitic 
subject.  He  thinks  it  might  be  better  for  a  syphilitic  sub- 
ject to  contract  typhoid  or  paratyphoid  fever  than  to  run 
the  risk  of  developing  paresis.  If  the  soldier  happened  to 
be  not  only  syphilitic  but  alcoholic,  then  the  danger  would 
be  larger.  Possibly,  however,  both  BonhoefTer's  case  of  anti- 
typhoid inoculation  epilepsy  and  the  cases  alluded  to  by 
Paris  of  antityphoid  inoculation,  are  merely  statistical 
accidents.  ♦ 


86  EPILEPTOSES 


Shell-shock;  (apparently  slight)  scalp  wound: 
Jacksonian  seizures.  Operation,  decompressing 
the  edematous  upper  Rolandic  region.     Recovery. 


Case  66.     (Leriche,  September,  191 5.) 

A  Moroccan  of  the  Seventh  Tirailleurs  was  thrown  to  the 
ground  by  the  explosion  very  near  him  of  a  large  calibre  shell, 
lost  consciousness,  and  woke  up  with  a  slight  contusion  of 
the  right  side  of  the  head.  The  date  of  this  injury  is  un- 
known. He  was  evacuated  to  the  interior,  but  stopped 
May  25,  1915,  at  the  evacuation  hospital  because  his  pulse 
in  the  train  stood  at  51.  An  hour  later  in  the  hospital  he 
had  a  Jacksonian  epileptic  attack,  followed  by  a  left-sided 
flaccid,  brachial  monoplegia,  and  after  a  quarter  of  an  hour  a 
second  crisis,  and  then  a  third,  —  a  sort  of  epileptic  status 
occupying  an  hour.  The  attack  seemed  to  start  in  the  left 
hand.   After  the  crisis,  hand  and  arm  became  flaccid  and  inert. 

Lumbar  puncture  in  the  crisis  gave  fluid  under  small 
tension  in  a  few  absolutely  limpid  drops.  The  wound  was  a 
superficial  skin  wound  as  big  as  a  25-centime  piece,  near  the 
middle  line,  roughly  corresponding  with  the  upper  Rolandic 
region.  It  was  hardly  a  wound  —  a  mild  abrasion  not  pass- 
ing the  epidermis;  periosteum  and  bone  intact. 

The  patient  was  trephined  and  a  thin  layer  of  clot  was  found 
over  the  dura  mater.  The  clot  was  removed  and  a  crucial 
incision  was  made  into  the  dura  mater.  The  brain  seemed  a 
little  edematous,  hemorrhagic  and  bruised.  It  soon  began  to 
beat  and  was  tamponed. 

May  26,  complete  brachial  monoplegia  without  seizure. 

May  27,  seizure  at  2  in  the  afternoon,  starting  in  left  arm. 

The  wound  was  going  well  and  from  this  time  forward 
no  more  seizures.     May  28,  a  cast  was  made  for  the  hand. 

June  4,  lumbar  puncture  yielded  a  clear  liquid  under  the 
pressure  of  58.  That  evening  an  hour  after  the  puncture, 
the  brachial  monoplegia  disappeared.  The  arm  was  still  a 
little  weak  June  5.  June  8  the  man  was  evacu'ated  to  the 
auxiliary  hospital  at  Laversine.     June  18,  complete  recovery. 


EPILEPTOSES 


87 


Fall  and  blow  to  head:    Hysterical  convulsions. 
Cure  by  studied  neglect. 


Case  67.     (Clarke,  July,  1916.) 

Clarke  had  seen  in  the  war  but  one  case  of  hysterical 
convulsions,  though  this  particular  patient  had  severe  hystero- 
epileptic  fits  occurring  in  series.  The  man  had  never  suffered 
from  epilepsy  and  was  20  years  of  age.  He  received  a  slight 
wound  and  fell  back  into  the  trench  a  distance  of  six  feet, 
striking  but  not  contusing  the  back  of  his  head. 

On  admission  to  the  hospital  he  was  found  drowsy  and  dull. 
Fits  occurred  a  week  later,  following  one  another  at  brief 
intervals  in  series  that  lasted  one  or  two  hours.  The  arms 
would  be  raised  and  extended  in  clonic  spasm;  the  patient 
would  resist  violently  if  held,  and  then  turn  to  his  right  side 
with  rigid  extension  of  legs  and  back  in  opisthotonos.  The 
eyeballs  underwent  irregular  movements,  and  there  was  a 
well  marked  hippus.  Though  the  tongue  was  protruded  in 
these  attacks,  it  was  never  bitten.  It  was  doubtful  whether 
there  was  a  complete  loss  of  consciousness.  Between  at- 
tacks, the  patient  was  morose  and  sullen,  and  showed  a  vary- 
ing incoordination  of  the  movements  of  the  left  leg,  which 
was  anesthetic  to  the  knee.  There  was  also  a  glove  anes- 
thesia of  the  right  forearm  and  hand.  Fields  of  vision  were 
contracted. 

The  fits  recurred  with  intervals  of  a  day  or  two,  for  a 
fortnight.  The  patient  was  then  strictly  isolated  in  a  small 
room  with  an  observation  window.  His  bed  was  made  up 
on  the  floor.  He  then  had  very  slight  attacks,  as  a  rule  when 
the  nurse  came  into  the  ward;  no  notice  was  taken  of  these 
attacks  and  in  a  fortnight  they  ceased.  The  paresis  of  the 
leg  and  the  anesthesia  also  cleared  up  without  treatment. 
He  remained  in  the  general  ward  three  weeks  longer,  at  first 
dull  and  listless,  but  later  cheerful  and  active.  Clarke 
suggests  that  this  patient  was  below  normal  intelligence. 


88  EPILEPTOSES 

Shell  injury  with  unconsciousness;  delayed  at- 
tacks of  epilepsy :  superposed  hysterical  hemihypes- 
thesia.  Previous  history  consistent  with  the  hy- 
pothesis that  a  genuine  epilepsy  had  been  developed. 


Case  68.     (Bonhoeffer,  July,  191 5.) 

An  excellent  soldier,  of  good  build,  29  years,  a  member  of 
the  Landwehr,  passed  unscathed  through  eleven  battles  in  the 
1914  campaign,  but  finally  succumbed  to  fragments  of  shell 
which  struck  his  chest  and  the  lower  part  of  his  thigh.  He 
fell  down,  nauseated,  and  lost  consciousness.  He  is  said  to 
have  struck  about  him  with  his  arm  and  to  have  voided  urine. 
There  was  a  second  attack  three  weeks  later,  in  which  he 
fell  upon  his  face. 

In  the  Charite  Clinic  he  had  three  attacks,  two  of  them 
nocturnal,  one  in  the  daytime,  followed  by  a  long  period  of 
somnolence.  He  once  cried  out  suddenly  in  the  night  as  if 
warding  off  an  attack.  He  complained  of  headaches,  and  was 
often  irritated  and  out  of  humor.  Somatically,  there  was  a 
hemihypesthesia  on  the  side  of  the  injury. 

The  history  indicates  that  this  patient  up  to  his  sixteenth 
year  had  been  a  victim  of  occasional  enuresis,  often  cried  out 
in  his  sleep  or  even  rose  from  bed.  Occasionally  he  suffered 
from  such  violent  sudden  headaches  that  he  would  have  to 
sit  down.  He  was  easily  irritated,  and  had  once  been  ar- 
rested for  assault.  As  a  soldier,  however,  he  had  never  been 
guilty  of  any  breach  of  discipline.  Mild  headaches  would 
follow  drinking.  These  phenomena  in  the  history  pointed 
in  the  direction  of  epilepsy.  According  to  Bonhoeffer,  we 
cannot  entirely  exclude  contusion  of  the  brain  from  the  shell 
injury.  However,  there  were  no  cerebral  symptoms,  and 
the  interval  before  the  occurrence  of  the  attacks  rather  in- 
dicates that  we  are  dealing  with  a  genuine  epilepsy.  As  for 
the  hemihypesthesia,  this  is  a  hysterical  "  superposition," 
which  does  not  interfere,  according  to  Bonhoeffer,  with  the 
genuineness  of.  the  epilepsy. 


EPILEPTOSES  89 


Shell- wound ;   musculocutaneous  neuritis:  Brown- 
Sequard's  epilepsy. 


Case  69.     (Mairet  and  Pieron,  January,  1916.) 

An  infantryman,  30,  a  gardener,  was  wounded  in  the  right 
forearm  by  a  shell  fragment,  which  fractured  the  ulna,  Sep- 
tember 7,  1914,  at  Revercourt.  Despite  much  fragmentation 
of  the  bone  and  suppuration,  the  wound  healed  with  two 
cicatrices,  where  the  fragments  had  gone  in  and  had  come 
out.     The  scarring  process  was  over  in  December. 

However,  in  the  middle  of  January,  191 5,  this  man  began  to 
suffer  from  headaches  and  insomnia,  with  vertigo  and  buzzing 
in  the  head,  "  as  if  an  airplane  inside."  Sometimes  arms 
and  legs  would  stiffen,  and  the  man  would  tremble,  have  to 
lie  down,  and  even  lose  consciousness  for  a  quarter  of  an  hour, 
waking  up  tired,  wandering,  and  with  feelings  in  his  head. 
These  crises,  at  first  occurring  every  week,  later  grew  fre- 
quent. Finally  there  was  a  very  complete  attack,  in  which 
he  fell  out  of  bed,  got  up,  made  several  turns  about  the  room, 
and  went  back  to  bed ;  and  in  the  morning,  was  dull  and  dis- 
oriented. Accordingly,  he  was  sent  to  the  central  military 
neuropsychiatric  service  of  the  general  hospital  at  Mont- 
pellier,  November  10, 

Besides  the  two  extensive  cicatrices,  there  were  motor 
disorders.  Pronation  and  supination  were  almost  impossible, 
as  well  as  extension  of  the  hand  and  fingers  and  abduction  of 
the  thumb.  There  was  a  radial  paralysis  without  R.  D. 
Electrical  excitability  of  the  extensors  was  diminished  on 
the  right.  The  hand  was  weak.  The  right  thumb  was 
atrophic.  There  was  a  hypertrichosis  as  well  as  redness,  heat 
and  perspiration  of  the  right  hand.  There  was  a  hypesthesia 
for  all  forms  of  stimulation  In  the  hand,  especially  In  the 
radial  region;  less  In  the  ulnar  region.  This  hypesthesia  rose 
along  the  posterior  surface  of  the  forearm  and  covered  all 
the  territory  of  the  ulnar  nerve ;  but  there  was  a  correspond- 
ing hyperesthesia  in  the  musculocutaneous  distribution,  as 
well  as  In  the  internal  cutaneous  distribution.     i\bove  the 


90  EPILEPTOSES 

scar^there  was  a  region  of  complete  anesthesia.  The  hyperes- 
thesia rose  higher  along  the  circumflex  nerve  and  the  posterior 
branches  of  the  cervical  nerves  and  included  the  great  occipi- 
tal distribution,  even  involving  the  superficial  cervical  plexus, 
though  not  the  territory  of  the  trigemini.  There  was  some 
hyperesthesia  of  areas  governed  by  a  few  dorsal  intercostal 
nerves.  There  were  also  spontaneous  pains  in  these  hyper- 
algesic  regions.  The  musculocutaneous  nerve  could  be  felt  to 
be  thick  and  swollen,  indicating  a  perineuritis.  There  were 
no  neuropathic  stigmata,  but  the  knee-jerks  were  exaggerated 
a  little  more  on  the  right  side. 

The  convulsions  appeared  two  or  three  times  a  day,  the 
pain  would  get  worse  along  the  arm,  rise  to  the  head,  follow- 
ing the  hyperesthetic  zone,  then  invade  the  interior  of  the 
head,  whereupon  objects  would  appear  to  turn  and  the  ears 
would  buzz.  The  right  leg,  and  especially  the  right  arm, 
would  begin  to  tremble.  The  man  would  have  to  support 
himself  to  avoid  falling.  He  saw  shadows  moving,  colored 
trees,  occasionally  persons.  When  the  vertigo  got  stronger, 
he  lost  consciousness.  The  extremities  of  the  right  side 
stiffened  and  carried  on  jerky  movements.  These  some- 
times extended  to  the  left  side.  The  seizure  lasted  from  five 
to  fifteen  minutes,  and  sometimes  occurred  in  the  middle  of 
the  night.  Fatigue  followed  but  headache  disappeared  after 
an  attack. 

The  diagnosis  of  Brown-Sequard's  epilepsy  was  made.  If 
the  musculocutaneous  trunk  was  compressed,  a  crisis  was 
produced  with  pain  radiating  to  the  head,  obscuration  of 
vision,  numbness  in  the  arm,  and  tremors.  Electrical  treat- 
ment was  resorted  to  for  analgesic  effect.  There  was  a 
certain  improvement  during  May,  so  that  the  diurnal  diz- 
ziness disappeared.  May  19  he  had  a  period  of  24  hours 
without  any  vertigo.  In  June  no  further  improvement 
occurred. 

An  operation  was  performed  June  23,  191 5.  The  two 
cicatrices  were  excised,  and  some  fragments  of  cloth  were 
removed.  Three  Jacksonian  crises  followed  the  operation, 
and  there  was  another  seizure  next  day.  Frequent  head- 
aches followed  without  crises.     More  seizures  appeared  in 


EPILEPTOSES  91 

the  night  during  July,  and  their  frequency  increased.  Pains 
persisted  along  the  arm  and  in  the  back  of  the  head;  the 
musculocutaneous  perineuritis  was  still  intense.  Prolonged 
baths  for  the  arm  were  begun  August  4,  tv/o  baths  of  two 
hours  each,  at  40  deg.  each  day.  Following  August  10 
there  was  an  improvement,  which  stopped  as  soon  as  the 
baths  were  omitted,  with  diminution  of  the  vertigo  and  the 
hyperesthesia.  This  improvement  continued ;  the  baths  were 
made  to  last  three  hours.  There  were  no  attacks  from 
August  21  to  26  whereupon  they  then  returned  for  two  days. 
The  pains  had  much  diminished  in  the  arm  but  persisted 
in  the  occiput.  A  few  night  attacks  occurred  August  30 
and  31,  September  5  and  6,  as  well  as  September  19  and  20, 
25  and  26,  and  27. 

The  occipital  pain  had  now  become  less;  the  musculocu- 
taneous nerve  was  not  so  large.  Only  a  few  headaches 
followed  during  the  months  of  October,  November,  and 
December.  After  November  3  the  baths  were  stopped  and 
the  arm  was  kept  wrapped  in  a  warm  compress.  There  was 
still  a  certain  hyperesthesia,  the  knee-jerks  had  become  less 
exaggerated.  Message  and  mechanotherapeutic  exercises 
were  begun.     There  were  no  more  attacks  after  September  2"]. 

Re  Brown-Sequard's  epilepsy,  Lepine  remarks  that  besides 
the  case  of  Mairet  and  Pieron,  Hurst  and  Souques  have  pub- 
lished cases.  Lepine  himself  has  observed  two  cases:  one 
followed  a  nerve  wound  in  the  foot;  another,  a  penetrating 
wound  of  the  chest.  As  a  rule,  such  Brown-Sequard  epi- 
lepsies appear  a  number  of  months  after  trauma,  as  a  result 
of  irritation  in  the  scar.  Lepine's  subjects  were  taken  for 
simulators  because  they  had  not  received  any  cranial  wound. 
The  prognosis  should  be  guarded,  though  the  outcome  in 
Case  69  appears  to  have  been  favorable. 


92  EPILEPTOSES 


Epileptic  episode  at  24  years  following  bullet-wound 
of  hand,  in  a  soldier  who  had  had  convulsions  in 
childhood  (sister  epileptic) .  Reactive  epilepsy  ?  Epi- 
lepsia tarda  ? 


Case  70.     (BoNHOEFFER,  July,  191 5.) 

A  man  in  the  reserve,  24,  bore  the  stresses  of  the  war  very 
well  in  the  campaign  in  East  Prussia  until  he  was  shot  in  the 
hand  at  Deutsch-Eylau,  He  had  always  been  well  aside 
from  rheumatism,  and  was  discharged  with  a  good  record 
from  his  military  service. 

Sent  to  the  reserve  hospital  for  his  hand  injury,  he  had, 
two  or  three  times  in  the  night,  convulsions  with  loss  of 
consciousness  and  dilated  pupils;  after  which  there  was  a 
thirty-six  hour  period  of  depression  with  refusal  of  food. 
Thereafter  this  soldier  had  amnesia  for  both  the  seizures 
and  the  subsequent  depression.  He  was  observed  six  weeks 
longer  in  the  Charite  Clinic  but  had  no  more  attacks,  and 
indeed  nothing  more  of  note  either  mentally  or  somatically. 

The  history  showed  that  there  had  been  convulsions  in  the 
third  and  fourth  years  of  the  patient's  life.  There  had  been, 
however,  nothing  epileptoid  in  the  later  childhood  or  develop- 
mental years  of  the  patient.  However,  a  sister  of  the  patient 
had  suffered  since  childhood  from  convulsions.  It  remains 
a  question  whether  this  episode  is  to  be  regarded  as  reactive 
epilepsy  —  reactive,  namely,  to  experiences  in  the  war  —  or 
whether  we  are  dealing  with  a  true  epilepsia  tarda. 

Re  this  episode  following  bullet  wound,  the  compiler  has 
placed  it  after  Mairet  and  Pieron's  case  of  Brown-Sequard 
epilepsy,  but  apparently  Bonhoefifer  regards  his  case  as  prob- 
ably a  reactive  one.  Unlike  the  case  of  Mairet  and  Pieron, 
Bonhoeffer's  case  had  an  epileptic  soil  (convulsions  in  child- 
hood and  epileptic  sister).  Re  the  so-called  reactive  epi- 
lepsies, see  remarks  by  BonhoefTer  under  Case  57. 


EPILEPTOSES  93 


Epilepsia  tarda  in  a  lance-corporal  without  heredi- 
tary taint  or  previous  history  save  dizzy  spells  and 
excitability. 


Case  71.     (BoNHOEFFER,  July,  1915.) 

A  reserve  lance-corporal,  24  years  — a  soldier  from  191 1 
to  191 3  without  disciplinary  record,  and  in  his  second  year 
becoming  lance-corporal — was  in  the  campaigns  in  Belgium, 
East  Prussia,  and  Poland,  making  long  marches  and  going 
through  several  battles.  In  the  middle  of  October,  19 14, 
he  fell  from  a  horse  and  suffered  a  contusion  of  the  thorax, 
after  which  blood  appeared  in  the  sputum.  In  November  he 
was  brought  to  the  reserve  hospital  in  Berlin,  and  there  had 
convulsive  seizures.  Before  transfer  to  the  Charite  Clinic,  a 
seizure  occurred,  and  he  was  brought  into  the  clinic  in  a 
characteristic  dazed  state.  Thereafter  he  was  clear  but  often 
out  of  humor  and  irritated.  Three  weeks  later  came  a  brief 
attack,  probably  epileptic  in  nature,  with  restless  half- 
delirious  sleep  following. 

There  was  nothing  in  childhood  or  in  the  family  history 
to  indicate  epilepsy.  However,  the  patient  himself  stated 
that  from  1913  onward,  after  his  period  of  military  service, 
he  had  from  time  to  time  felt  attacks  of  dizziness  after 
exertion,  and  that  he  had  become  more  easily  excitable  than 
before. 

The  attacks  in  the  lance-corporal  are  probably  not  to  be 
attributed  to  the  thoracic  contusion,  according  to  Bonhoeffer, 
because  of  the  long  period  that  elapsed  after  the  thoracic 
injury,  and  their  development  nocturnally  without  special 
occasion.  According  to  Bonhoeffer,  we  are  probably  here 
dealing  with  a  late  epilepsy. 

Re  late  epilepsy,  see  also  under  Case  57.  Bonhoeffer  makes 
a  considerable  point  of  the  lateness  in  attacks  of  epilepsy  in 
some  of  the  military  cases,  pointing  out  their  beginning  at 
the  ages  of  22  to  27  in  the  period  of  peace  practice  under- 
gone by  soldiers.  The  theory  is  that  cases  of  severe  and 
long-standing  epilepsy  are  known  to  the  authorities,  so  that 


94  EPILEPTOSES 

they  would  not  ordinarily  be  in  military  service  except  under 
conditions  of  concealment  or  in  case  of  error.  The  present 
case  (71)  appears  to  be  the  nearest  that  Bonhoeffer  has 
found  to  a  case  of  epilepsy  without  heredity  and  without 
acquired  soil.  All  that  can  be  regarded  as  evidence  of  soil 
is  the  dizzy  spells  and  excitability. 

Re  thoracic  contusion,  compare  remarks  of  Lepine  under 
Case  69,  on  Brown-Sequard  epilepsy  following  thoracic 
wound. 


EPILEPTOSES  95 

Convulsions  by  autosuggestion. 


Case  72.     (Hurst,  November,  1916.) 

A  private,  2'],  is  described  as  a  typical  martial  misfit  — 
in  private  life  a  music  hall  falsetto  singer,  and  afterward  a 
valet.  He  joined  the  army  in  191 5  and  proceeded  to  France, 
and  worked  in  a  canteen.  A  week  later,  men  broke  in  and 
threw  a  mallet  at  him,  whereupon  he  immediately  had  a  fit, 
and  was  dazed,  dumb,  and  unable  to  walk  for  two  days. 
Thereafter  occasional  further  fits  occurred,  with  nervous- 
ness and  insomnia.  He  was  sent  home  in  September,  1916. 
Discharged  to  duty,  he  again  in  December  returned  to  France, 
had  six  fits  in  the  first  week  —  three  in  hospital,  two  on  the 
boat,  and  between  two  and  four  for  four  days  after  admission. 
The  diagnosis  of  genuine  epilepsy  was  made  in  France  by  a 
medical  officer  who  had  seen  one  of  the  convulsions.  How- 
ever, he  had  never  passed  urine  or  bitten  his  tongue,  had  no 
family  history,  and  had  never  had  fits  before  going  to  France. 

He  was  hypnatized  and  given  the  suggestion  that  he  would 
have  a  fit.  In  the  convulsion  which  followed  the  plantar  re- 
flexes remained  flexor,  but  otherwise  the  convulsion  was 
quite  like  the  genuine  epilepsy.  He  was  told  that  he  would 
not  have  any  more  convulsions,  nor  did  he  have  any  more 
except  on  Feb.  16,  191 7,  when  some  talk  was  made  to  him 
about  returning  to  duty.  Bromides  used  in  France  did  not 
help  the  epilepsy  at  all.  This  patient  deyeloped  a  gait  and 
speech  defect  copied  from  two  patients  in  the  wards.  These 
symptoms,  due  to  autosuggestion,  disappeared  on  persuasion. 
Re  autosuggestion,  Bernheim  has  returned  to  the  fray 
(19 1 7)  in  a  book  on  automatism  and  suggestion,  dealing  only 
in  small  part  with  war  problems.  The  most  general  formula 
for  suggestion  appears  to  be  that  it  is  an  idea  accepted.  A 
suggestion  offered  but  not  accepted  is  in  effect  not  a  sugges- 
tion at  all.  Any  accepted  idea,  says  Bernheim,  is  from  the 
psychological  point  of  view  as  well  as  from  the  medical  point 
of  view,  a  suggestion.  A  suggestion  may  be  direct  or  in- 
direct, reasonable  or  unreasonable,   brought  about  by 


g  EPILEPTOSES 

{a)   mere  verbal  assertion, 

(b)  hypnotic  state, 

(c)  persuasive  explanation,  rational  or  emotional, 

S   emotion  (that  is,  emotion  not  the  effect  of  any  form  o 
suLestion  ofTered  by  the  physician,  but  emotion  brought 
about  by  some  event  affecting  the  sentiments  of  the  subject). 


EPILEPTOSES  97 

Epilepsy  of  emotional  origin. 


Case  73.     (Westphal  and  Hubner,  April,  1915.) 

A  lieutenant  without  neuropathic  tendencies  (except  that 
his  mother  was  in  a  hospital  for  the  insane)  was  under  shell 
fire  for  some  time.  Finally,  a  shell  burst  near  him,  whereupon 
headaches  and  transient  spells  of  confusion  followed.  Shortly 
upon  the  news  of  the  death  of  his  Major,  he  had  a  spell  of 
violent  excitement  and  confusion,  dancing  about  on  the 
ground  and  breaking  things  up.  He  passed  into  a  stuporous 
condition  with  a  suggestion  of  catatonia.  There  were  a  few 
isolated  delusions  to  the  effect  that  he  was  poisoned.  After 
sleeping  a  long  time,  he  suddenly  cleared  up.  There  was  an 
extensive  amnesia  covering  a  period  of  weeks.  He  had  for- 
gotten the  Major's  death  and  everything  thereafter.  He 
complained  of  headache,  difficulty  of  thinking,  and  forgetful- 
ness.  An  agoraphobia  developed,  as  well  as  great  sensitivity 
to  sounds,  and  a  feeling  as  if  the  bed  and  surrounding  barracks 
were  moving.  There  were  a  few  illusions  of  a  visual  nature. 
He  had  complete  insight  into  his  condition.  Conduct  was 
normal.     There  was  general  hyperesthesia  and  ageusia. 

According  to  Westphal,  this  case  of  deep  disorder  of  con- 
sciousness of  some  duration  in  a  healthy  person  is  probably 
one  of  a  dazed  state  following  the  so-called  "  affect  epilepsy." 

Is  Case  73  Shell-shock?  Note  that,  In  Case  73,  the  shell 
explosion  at  first  occasioned  mere  headaches  and  confusional 
spells.  The  true  occasion  of  the  convulsions  appears  to  have 
been  the  news  of  the  death  of  a  superior  officer.  It  is,  of 
course,  possible  that  the  transient  spells  of  confusion  were 
actually  epileptic  equivalents.  Lepine  remarks  that  Pierret 
and  others,  observing  such  spells  of  confusion  often  accom- 
panied by  agitation,  have  inquired  whether  manic  depressive 
psychosis  is  not  a  kind  of  epilepsy.  This  question  remains 
unresolved.  These  phenomena  of  epilepsia  larvata  (see  also 
Case  81  of  Juquelier  and  Quellien)  are  to  be  sharply  distin- 
guished from  attacks  of  confusion  occurring  in  pronounced 
epileptics.  These  latter  attacks  often  follow  a  crisis  and 
suggest  exhaustion;    sometimes  they  last  several  days. 


98  EPILEPTOSES 


Fatigue ;  fear ;  hysterical  convulsions.  Visual  aura 
(approaching  fire  wheel)  built  up  after  the  third  crisis 
(scotoma  after  look  at  sun). 


Case  74.     (Laignel-Lavastine  and  Fay,  July,  191 7.) 

A  sapper,  23,  with  his  company  under  heavy  bombardment, 
October,  1916,  was  overcome  by  weariness  and  fear  (he  had 
always  been  of  a  timorous  disposition).  The  order  for  the 
rear  came,  but  the  convoy  was  hardly  en  route  when  the 
sapper  felt  a  griping  in  the  pit  of  the  stomach  and  the  blood 
going  to  his  head ;  whereupon  he  lost  consciousness  and  went 
into  convulsions. 

This  incident  seems  to  have  made  a  powerful  impression 
upon  the  sapper,  A  fortnight  later,  while  working  In  the 
trenches,  he  had  more  epigastric  sensations  with  vague  dis- 
comfort. He  thought  about  the  earlier  crisis  and  about  his 
wounded  comrades,  and  again  fell  down  and  had  more  con- 
vulsions lasting  a  quarter  of  an  hour.  The  tongue  may  have 
been  slightly  bitten  in  this  seizure.  In  the  genesis  of  this 
second  seizure  we  may  consider  that  the  feeling  of  discomfort 
and  the  epigastric  sensations  served  to  recall  the  first  seizure, 
so  that  the  second  one  may  be  regarded  as  due  to  auto- 
suggestion —  that  is,  as  hysterical. 

A  little  later,  on  a  hot  day  in  the  trench,  while  working, 
the  sapper  turned  to  a  comrade  and  saw  a  great  black  spot 
on  his  face.  He  turned  toward  another  and  saw  another 
great  black  spot  on  this  face  also.  He  was  frightened,  felt 
strange  sensations,  fell,  and  had  a  third  convulsive  crisis. 
The  black  spots  that  he  saw  were  due  to  a  scotoma,  the 
result  of  a  transient  glance  at  the  sun. 

After  this  scotomatous  episode,  his  crises  always  had  a 
visual  aura.  He  would  feel  rather  uncomfortable,  leave  the 
supper  table,  feel  a  gastric  sensation,  warmth  in  the  face,  and 
oppression.  He  would  go  out  in  the  cold  for  the  air,  look 
about  for  something,  appear  frightened,  fix  his  gaze  upon  a 
certain  point,  and  cease  to  reply  to  questions.'  His  head 
would  jerk  back  suddenly,  and  he  would  utter  strangled  cries 


EPILEPTOSES  99 

of  fear.  He  was  now  evidently  prey  to  a  terrifying  hallu- 
cination. In  ten  minutes,  everything  had  gone  again,  leaving 
him  trembling  with  emotion.  He  would  then  relate  how, 
after  the  epigastric  sensation  had  begun,  he  tried  to  see  if  he 
could  make  out  something  abnormal;  whereupon  a  little 
fiery  wheel  would  appear  and  roll  up  nearer  and  nearer,  so  as  to 
almost  touch  his  eyelids.  He  could  see  his  comrades  to  the 
right  and  to  the  left  of  the  wheel ;  he  could  hear  questions  but 
could  not  answer.  Just  as  the  fire  wheel  was  about  to  blast 
him,  consciousness  was  lost  and  the  fits  came  on. 


100  EPILEPTOSES 


War  strain ;  anxiety ;  confusion ;  fugue.     Demotion 
and  detail  to  the  interior. 


Case  75.     (Barat,  November,  1914.) 

A  lieutenant,  25,  an  officer  in  a  regiment  on  active  duty 
near  the  front,  was  called  before  a  special  board  charged  with 
desertion  in  the  face  of  the  enemy.  He  had  been  assigned  to 
a  certain  position  but  not  only  had  not  complied  with  the 
order,  but  had  wandered  off  to  the  British  sector  and  been 
arrested  there  as  a  spy. 

The  prisoner  was  well  developed,  without  stigmata;  hered- 
ity, negative.  His  career  in  the  army  had  been  courageous 
and  he  had  been  advanced  several  ranks  and  was  about  to 
be  given  a  medal  for  bravery.  He  said  that  he  had  been 
under  a  severe  strain  for  several  days. 

One  evening  he  had  been  given  the  order  to  attack.  The 
artillery  opened  fire.  He  found  that  the  Germans  had  erected 
barbed  wire  defences.  The  loss  of  men  was  terrific.  His  order 
was  to  shoot  all  who  held  back.  A  poor  territorial  crouched 
down  and  would  not  go  forward  —  supplicating  the  prisoner 
not  to  shoot  him.     The  prisoner  spared  him. 

The  next  night  the  order  to  attack  the  German  trenches 
was  again  given.  This  time  he  was  overcome  with  anxiety 
and  discouragement.  The  last  he  remembers  was  the  order 
to  attack.  Next  day  he  felt  sick  and  his  mind  was  foggy. 
He  remembered  leaving  his  regiment  and  wandering  round 
for  several  days  until  he  fell  into  the  hands  of  the  British 
and  was  arrested.     Then  he  understood  what  he  had  done. 

The  prisoner  asked  to  be  allowed  to  return  to  the  front. 
The  testimony  of  one  of  the  lieutenant's  men  verified  his 
statements.  On  the  day  before  he  left  the  front  he  had  been 
anxious,  had  cried  often,  and  would  speak  to  no  one.  On 
the  day  he  left  the  trenches  w^ithout  permission,  he  was 
nervous  and  disoriented. 

There  was  no  doubt  that  simulation  could  be  ruled  out; 
the  differential  diagnosis  lay  between  a  "  confused  state  of 
emotional  origin  "  and  an  "  epileptic  dazed  state." 


EPILEPTOSES  lOI 

For  epilepsy  there  was  a  history  of  attacks  with  falling  to 
the  ground  and  loss  of  consciousness,  without  involuntary 
micturition  or  biting  of  tongue,  during  the  time  when  he  was 
a  sergeant.  Moreover,  irritability  and  unwarranted  sus- 
piciousness had  been  present  at  these  periods.  However, 
there  were  no  other  epileptic  symptoms;  these  two  attacks 
were  isolated  and  of  quite  long  duration,  leaving  no  head- 
ache or  malaise  after  them.  Also  there  was  no  basis  for  the 
diagnosis  "  epileptic  dazed  state,"  since  there  was  no  abrupt 
commencement;  the  loss  of  consciousness  was  never  com- 
plete (the  subject  was  able  to  converse  with  persons  while  the 
attacks  were  on) ;  and  some  remembrance  was  present  of 
incidents  during  the  attacks. 

For  Barat,  the  important  points  are  that  the  attacks  were 
preceded  by  long  periods  of  anxiety  and  the  disturbances 
resulted  more  from  moral  than  physiological  causes. 

The  importance  of  the  psychological  factors  lead  the  author 
and  his  colleagues  to  the  diagnosis  "  Mental  confusion  of 
emotional  origin." 

The  board  decided  to  return  him  to  the  interior  and  give 
him  a  barracks  position  at  the  reduced  rank  of  drill  sergeant. 


102  EPILEPTOSES 


A  solitary  epileptic  episode  in  an  artillery  officer 
(slight  concussion  of  the  brain  two  years  before) 
following  extraordinary  campaign  stress  (38  artillery 
battles  in  two  months). 


Case  76.     (BoNHOEFFER,  July,  191 5.) 

A  first  lieutenant  of  artillery,  35,  was  able  to  count  38 
artillery  clashes  in  which  he  had  taken  part  in  two  months 
of  very  strenuous,  almost  daily  fighting.  Then  appeared 
headaches,  anxiety,  dizzy  feelings,  insomnia.  Finally  one 
day  suddenly,  after  eating,  the  lieutenant  sustained  a  loss  of 
consciousness  with  convulsions,  which  sent  him  to  his  home 
reserve  hospital.  The  ofhcer  had  felt  nothing  before  his 
convulsions  came  on.  The  medical  report,  however,  yields 
no  doubt  of  the  epileptic  character  of  the  attack. 

When  he  was  examined,  there  was  a  slight  psychopathic 
depression  with  a  feeling  of  insufficiency,  anxiety,  insomnia, 
restless  dreams,  over-sensitiveness,  and  a  pessimistic  out- 
look on  the  future.  There  were  no  epileptic  traits  whatever. 
There  was  nothing  alcoholic,  luetic,  or  arteriosclerotic  about 
the  officer.  There  was  nothing  in  the  childhood  or  youth  of 
the  patient,  though  there  had  been  a  fall  two  years  before, 
with  phenomena  of  concussion  without  sequelae.  In  fact, 
this  fall  with  concussion  had  led  to  no  medical  examination. 

As  to  the  relation  of  the  concussion  two  years  before  to  the 
epileptic  attack,  Bonhoeffer  Is  inclined  to  interpret  the  case 
as  one  of  genuine  "reactive  "  epilepsy  on  the  basis  of  con- 
tinuous overstrenuous  work  for  a  period  of  weeks.  He  re- 
gards the  previous  concussion  as  soil  for  this  epilepsy. 

Re  amount  of  stress  occasionally  required  to  bring  out 
epilepsy,  compare  Hurst's  Cases  64  and  80.  It  may  be 
recalled  that  Bonhoeffer  is  decidedly  of  the  belief  that  ex- 
haustion has  not  brought  about  any  actual  psychoses,  calling 
attention  to  the  remarkable  absence  of  psychoses  among  the 
Serbians  after  their  exhausting  campaigns.  A  general  re- 
view of  war  experience  Indicates,  according  to  Bonhoeffer, 
the  marked  power  of  resistance  of  the  healthy  brain. 


EPILEPTOSES  103 


Nocturnal  narcoleptic  seizures  accompanied  by 
spells  of  somnolence  in  the  day,  both  to  be  regarded 
as  due  to  the  *'  brain  fag  "  of  trench  life. 


Case  77.     (Friedmann,  July,  191 5.) 

A  tradesman,  23,  had  been  in  the  German  infantry  since 
the  beginning  of  the  war.  Never  sick,  he  had  been,  in  a 
general  way,  nervous;  and  a  brother  had  had,  at  the  age  of  30 
years,  some  sort  of  severe  brain  disease,  in  which  he  became 
blind,  dying  a  year  later. 

The  man  was  for  a  long  time  in  the  trenches  and  proved 
himself  a  courageous  and  stalwart  soldier.  He  went  to 
hospital  after  a  slight  bullet  wound  of  the  leg,  with  a  benign 
paralysis  of  the  peroneus. 

In  the  hospital  he  began  to  show  a  somewhat  pronounced 
emotional  depression,  with  a  nervous  tachycardia. 

Friedmann  reports  the  case  on  account  of  certain  peculiar 
seizures  which,  upon  the  man's  own  story,  had  begun  five 
weeks  before,  in  the  field,  although  he  had  told  no  one  about 
them.  He  had  never  felt  anything  like  them  before.  At 
first,  they  came  three  to  five  times  almost  every  night.  He 
would  suddenly  wake  and  find  himself  unable  to  move,  to 
speak,  or  even  to  think.  These  seizures,  however,  were  not 
accompanied  by  any  feeling  of  anxiety  or  any  respiratory 
distress.  Consciousness  remained  clear,  and  after  10  or  15 
seconds,  he  could  begin  to  think  normally  again.  It  was 
clearly  a  question  of  psychopathic  absences  of  a  mild  nar- 
coleptic type,  occurring,  however,  only  at  night. 

Daytimes,  also,  throughout  the  whole  period  In  which 
the  nocturnal  absences  occurred,  there  were  seizures  of  an* 
other  description.  During  the  many  hours  in  which  he  had 
to  sit  in  the  trench,  about  twice  a  day  for  half  an  hour  long, 
he  would  plunge  suddenly  into  a  sort  of  irresistible  lethargy. 
Without  any  external  occasion  whatever,  there  would  be  a 
feeling  of  great  fatigue.  In  the  spell  he  could  not  move  or 
think,  would  lean  his  head  upon  his  hand.  He  was  unable 
to  overcome  the  feeling  of  weariness  and  became  convinced 


I04  EPILEPTOSES 

that  he  was  ill,  and  that  the  fatigue  could  not  be  natural. 
However,  he  did  his  work  like  the  rest.  Friedmann  inter- 
prets these  spells  as  a  kind  of  imperfect  sleep. 

The  patient  was  physically  healthy  and  stalwart,  mentally 
not  excitable,  and  tolerably  tranquil  in  the  midst  of  shell 
fire.  He  would  never  have  been  reported  sick  had  it  not 
been  for  his  wound.  Aside  from  the  tachycardia,  of  which 
he  himself  complained  little,  nothing  wrong  was  found  in  the 
hospital.  There  was,  to  be  sure,  a  feeling  of  discomfort 
without  any  hysterical  tinge,  and  sleep  was  restless.  Aside 
from  the  peroneus  palsy,  the  injury  made  a  good  recovery. 
The  nocturnal  attacks  persisted ;  bromides  and  even  luminal 
failed  of  effect.  There  was,  however,  no  longer  any  som- 
nolence by  day.  In  fact,  for  the  five  weeks  of  observation, 
there  was  no  change  In  his  condition. 

Friedmann  states  that  mild  emotional  alterations  are  not 
infrequent  in  the  trenches  with  minds  disposed  thereto, 
although  emotional  shock,  especially  in  shell  fire,  is  the  most 
frequent  cause.  However,  these  particular  seizures  are  quite 
unusual.  The  stresses  of  field  service  lead  to  a  sometimes 
complete  paralysis  of  mental  power,  interfering  transiently 
with  service.  There  is  no  evidence  of  sudden  circulatory 
disturbances  such  as  would  bring  about  dizziness,  pallor, 
nausea,  or  fainting  spells.  According  to  Friedmann,  the 
regulative  brain  functions,  especially  those  that  maintain 
consciousness,  become  weak  on  account  of  a  condition  which 
he  terms  Gehirnmudigkeit,  or,  as  we  should  say  in  English, 
brain  fag.  The  situation  forbids  due  completion  of  sleep. 
Thus,  the  explanation  of  the  daytime  attacks  follows  rather 
obvious  lines  of  brain  fag.  The  accidental  awakening  it  is, 
which  at  night  produces  the  absences;  the  wakenings  are  due 
to  the  general  restlessness  of  the  patient.  The  general  weak- 
ening of  cerebral  function  produces  the  disorder  at  the  mo- 
ment of  wakening,  since  the  regulative  factors  of  conscious- 
ness are  already  out  of  order.  The  condition  in  the  absence 
rather  closely  resembles  the  state  of  consciousness  just  before 
going  to  sleep,  and  also  perhaps  the  state  of  consciousness 
during  the  process  of  awakening.  It  is  as  if  the  process  of 
waking  were  somehow  delayed  a  few  moments.     Friedmann 


EPILEPTOSES  105 

is  interested  to  show  the  relation  of  such  absences  to  the  so- 
called  gehduften  kleinen  Anfdlle,  originally  described  by  him 
in  1906  as  occurring  in  children,  and  distinguished  from  epi- 
leptic attacks.  These  attacks,  after  lasting  for  years,  finally 
disappeared  completely.  The  same  sort  of  thing  in  adults 
was  symptomatic  of  some  other  disease,  such  as  neurasthenia, 
and  was  not  a  true  entity.  In  children  these  attacks  failed 
to  be  attended  with  any  mental  injury,  nor  were  there  any 
pronounced  epileptic  phenomena.  Bromides  had  no  effect 
upon  them,  and  they  already  showed  a  somewhat  striking 
and  peculiar  appearance,  involving  interruptions  ten  seconds 
long  of  capacity  to  think,  speak,  or  move,  without  disturb- 
ance of  consciousness  or  automatic  movements.  Sometimes 
the  attacks  occurred  from  six  to  100  times  in  the  day,  without 
in  any  respect  interfering  with  the  general  condition  of  the 
child.  The  occurrence  of  such  series  of  mild  seizures  is  noth- 
ing but  a  syndrome.  To  be  sure,  some  cases  turn  out  to 
be  cases  of  genuine  epilepsy  with  an  eventual  degenerative 
process.  Some  forms  belong  in  the  spasmophilia  group,  and 
some  among  the  hysterias.  However,  according  to  Fried- 
mann,  there  is  a  narcoleptic  petit  mat  that  is  an  entity  by  itself, 
proceeding  after  a  period  of  years  to  complete  recovery  with- 
out complications.  It  is  this  form  which  may  be  regarded 
as  a  peculiar  kind  of  brain  fag.  The  case  of  the  soldier  may 
be  supposed  to  be  one  which  will  prove  to  have  this  benign 
outcome. 


I06  EPILEPTOSES 


Sham  fits. 


Case  78.     (Hurst,  March,  1917.) 

An  unwilHng  conscript  developed  numerous  fits  on  board 
ship  coming  from  Jersey,  three  days  after  enUsting.  Fifty 
more  developed  during  two  days  in  hospital.  He  was  sent 
to  Netley. 

On  the  hypothesis  of  hysteria  or  malingering,  he  was  hypno- 
tized. A  fit  was  suggested  to  him,  but  did  not  come  ofT. 
The  Sister  was  informed  in  the  patient's  hearing  that  the 
man  was  clearly  shamming,  as  in  all  genuine  cases  a  fit  would 
occur  after  this  treatment.  A  fit  with  marked  opisthotonos 
immediately  occurred.  This  fit  immediately  stopped  when 
he  was  ordered  to  stop  it  and  to  wake  up. 

The  man  after  waking  promised  to  have  no  more  fits. 


Epileptoid  attacks,  controllable  by  will. 


Case  79.     (RussEL,  August,  1917.) 

A  man  was  received  in  No.  3,  General  Hospital:  Diagnosis, 
epilepsy.  He  was  shortly  sent  to  the  convalescent  camp 
and  then  returned,  having  had  two  attacks.  Russel  watched 
for  another  attack,  felt  it  was  not  genuine  and  "put  the 
situation  up  to  "  the  soldier  whose  story  was  as  follows:  He 
had  been  at  the  front  without  leave  for  twelve  months  since 
the  German  retreat.  Leave  was  due  him.  A  sister's  letter 
said  his  brother  was  severely  wounded  and  his  mother  was 
praying  for  his  return.  When  he  thought  these  things  over 
an  attack  came.  He  could,  however,  control  the  attacks. 
Russel  told  him,  if  he  would  play  the  game,  he  would  be  sent 
to  the  base  with  a  recommendation  for  leave.  In  ten  days 
the  man  was  remarkably  changed  and  had  no  further  attacks. 


EPILEPTOSES  107 

Hereditary  epileptic  taint  brought  out  by  two  years 
service  with  eventual  shell-shock  and  burial  thrice 
in  one  day. 


Case  80.     (Hurst,  March,  191 7.) 

A  private,  24,  in  the  army  from  16,  never  epileptic  (sisters 
epileptic),  was  wounded  four  times  in  the  war  from  Septem- 
ber, 1914.  Shell  fire  did  not  worry  the  man,  but  he  gradually 
became  depressed  after  his  father  and  five  brothers  had  died 
in  active  service.  He  was  blown  up  and  buried  three  times 
in  one  day  in  July,  1916.  He  was  unconscious  for  two  hours 
after  the  second  blowing  up,  but  carried  on  for  tv/o  hours 
more  until  blown  up  for  the  third  time. 

After  this,  he  became  nervous  and  shaky,  and  began  to 
sleep  badly,  and  a  month  later  had  a  typical  attack  of  major 
epilepsy.  Fits  occurred  with  increasing  frequency.  As 
many  as  19  occurred  in  a  single  day.  Rest  and  bromides 
caused  the  fits  to  cease,  and  there  had  been  none  for  six 
weeks  at  the  time  of  his  discharge. 

Re  the  extraordinary  delay  in  the  bringing  out  of  this 
epileptic's  taint,  refer  back  to  Case  76  of  Bonhoeffer,  with 
its  discussion,  and  to  another  case  of  Hurst  (64). 

Re  Shell-shock  and  its  relations  to  epilepsy,  see  below,  dis- 
cussion under  Cases  82-84  of  Ballard,  who  has  erected  a 
theory  of  Shell-shock  as  in  some  sense  epileptic. 


I08  EPILEPTOSES 

Shell-shock :  Epilepsia  larvata. 


Case  8i.     (Juquelier  and  Quellien,  May,  1917.) 

A  soldier,  29  (father  alcoholic,  died  in  hospital  for  the  in- 
sane), a  decorative  painter  without  plumbic  history,  non- 
alcoholic, non-syphilitic,  was  wounded  once,  September,  19 14, 
but  returned  to  the  front  in  191 5. 

May,  191 5,  a  shell  burst  near  him.  He  lost  conscious- 
ness, regained  it  a  few  days  later  at  Brest,  and  was  so  far 
recovered  that  he  could  go  on  leave  in  seven  days.  While 
on  leave,  he  had  short  attacks  of  delirium,  followed  by  a 
total  amnesia;  there  was,  however,  no  crisis,  fall,  or  convul- 
sion. After  the  first  attack,  he  had  for  24  hours  malaise  and 
headache,  but  got  well  and  went  back  to  his  depot.  Shortly 
afterward  more  attacks  of  this  sort  recurred,  and  he  went  to 
hospital  and  thence  to  the  neurological  centre  at  Tours. 
Whence,  August  9,  191 5,  he  got  a  two-months'  leave  for 
"mental  disorder  post-confusional,  second  Stat,  probably 
hysterical  {commotio  cerebri),  and  organic  hemiparesis." 

November,  191 5,  after  returning  to  the  dep6t,  there  were 
more  spells  and  he  went  again  to  hospital.  Invalided 
December,  191 5,  he  passed  a  year  at  home,  but  the  spells  con- 
tinued. Although  the  epileptic  nature  of  these  attacks  was 
maintained  by  Francals  at  Evreux,  he  was  placed  in  the 
auxiliaries,  December,  191 6,  but  had  to  go  to  hospital  almost 
at  once,  and,  February  28,  1917,  entered  the  neurological 
centre  of  the  9th  Region  for  the  second  time.  Here,  when 
called  to  be  examined  two  days  after  admission,  he  was 
observed  in  an  attack.  He  suddenly  rose  from  the  bench, 
made  a  few  steps,  seemed  to  be  listening  and  anxious,  as  If 
he  ought  to  be  on  guard.  He  looked  up,  seemed  to  be  look- 
ing for  something  whose  noise  was  approaching,  lowered  his 
head,  made  a  slight  jerking  movement,  and  said,  "Poum!" 
as  If  to  express  the  noise  of  an  explosion.  He  took  a  few 
more  steps,  the  same  movements  were  repeated,  and  the 
same  "Poum!  "  was  uttered.  This  lasted  for  about  a  quar- 
ter of  an  hour,  during  which  the  patient  was  unaware  of  his 
surroundings.     He  could  be  guided  all  about  the  hall  without 


EPILEPTOSES  109 

resistance,  but  did  not  respond  to  orders,  commands,  noises, 
or  contact.  In  short,  the  patient  was  in  the  midst  of  a 
hallucinatory  dream  at  his  post  in  the  trenches,  undergoing 
a  bombardment.  He  was  placed  in  a  chair;  remained 
motionless  for  a  few  seconds,  woke  up,  and  answered  ques- 
tions. "Where  am  I?  Oh,  yes;  I  must  have  been  sick 
because  my  head  feels  bad."  In  answer  to  the  question. 
"What  did  you  see;  what  was  there?",  he  said,  "I  don't 
remember  anything.  I  never  remember.  I  don't  know." 
The  patient  was  dull  and  weak  after  the  spell. 

These  spells  varied  in  number  but  occurred  once  a  week. 
The  patient  was  able  to  tell  of  certain  attacks  that  had 
occurred  while  he  was  out  of  doors  at  home. 

Now  and  then,  there  was  another  theme  in  the  halluci- 
natory delirium,  namely,  a  pencil  drawing  of  a  woman's 
picture,  of  no  great  artistic  worth  but  carefully  done,  at 
which  the  patient  was  much  astonished  on  awaking. 

It  seems  as  if  auto-  and  hetero-suggestion  can  be  elimi- 
nated from  the  genesis  of  these  attacks.  Neither  hysterical 
nor  epileptic  crises  have  preceded  or  ever  alternated  with 
these  seizures.  Nevertheless,  on  the  organic  side,  the  patient 
had  a  general  increase  of  tendon  reflexes  on  the  left  side,  most 
marked  in  the  knee-jerk,  and  fell  to  the  left  in  voltaic  ver- 
tigo. There  was  a  left  hemiparesis,  apparently  of  organic 
origin,  which  had  been  determined  as  far  back  as  July,  191 5. 

There  was  no  true  dementia.  Past  memories  were  but 
slowly  recalled,  and  inattention  interfered  with  the  fixation 
of  recent  memory.  He  complained  of  troubles  in  his  sleep 
and  dreamed  of  war  experiences  somewhat  analogous  to  those 
in  his  attack  of  amnestic  delirium.  After  the  seizure,  there 
was  a  marked  hebetude  and  mental  inactivity,  torpor,  and  a 
severe  headache.  The  case  was  presented  to  a  special  com- 
mission as  one  of  epilepsia  larvata  in  a  person  hereditarily 
predisposed  who  had  never  before  presented  epileptic  signs, 
suffering  from  a  disease  characterized  by  frequent  short 
attacks  of  hallucinatory  and  delirious  automatism,  following 
shell  explosion  which  had  at  the  same  time  produced  a  slight 
left-sided  hemiparesis  and  mental  inhibition. 


no  EPILEPTOSES 


To  illustrate   an   epileptic   theory  of  Shell-shock; 
three  cases: 

1.  Fugue;   minor  symptoms:   later,  epilepsy. 

2.  Epileptic   confusion   eight  months   after   ex- 

plosion. 

3.  Mine    explosion:     stammering    replaced    by 

mutism;   mutism  replaced  by  epilepsy. 


Case  82.     (Ballard,  191 7.) 

Atmospheric  concussion  from  shell  explosion,  October, 
1915,  was  followed  by  unconsciousness  in  a  soldier  described 
by  Ballard. 

Blindness  for  a  month  followed  recovery  of  consciousness. 
"Neurasthenia"  (anxiety  neurosis)  after  return  of  sight. 
Apparently  nearly  complete  recovery  after  latent  period  of 
a  few  weeks.  Return  of  blindness  in  one  eye  in  December. 
Five  days  automatic  wandering  (the  man  was  found  in  a 
west  country  town  five  days  after  leaving  home  to  rejoin  his 
depot  and  seen  by  a  medical  officer  who  reported  that  he  was 
dazed  and  amnestic  for  that  period) ;  admission  to  second 
Eastern  General  Hospital,  December  15. 

On  admission  he  proved  to  be  suffering  from  minor  hysteri- 
cal symptoms  such  as  an  inability  to  open  his  eyes  and  to 
see  clearly  when  the  lids  were  raised.  The  symptoms  rapidly 
cleared  up  under  suggestive  conversation  and  did  not  return 
except  for  amnesia  and  slight  emotional  depression.  He  re- 
mained well  until  December  25.  On  that  day  he  began  for 
the  first  time  to  have  definite  epileptic  fits  and  nocturnal 
epileptic  delirium.  In  January  he  was  discharged  as  an 
epileptic.  There  was  no  epileptic  temperament  or  feeble- 
mindedness. Finally,  there  had  never  been  any  personal  or 
family  neuropathic  or  psychopathic  history. 

Case  83.     (Ballard,  191 7.) 

A  soldier  was  blown  up,  April,  191 5,  and  had  a  spell  of 
unconsciousness.  Later,  pains  In  the  head,  slight  amnesia 
and  a  condition  of  asthenia  developed. 


EPILEPTOSES  III 

He  was  eventually  admitted  to  the  second  Eastern  General 
Hospital  at  Brighton,  January,  1916.  At  the  time  of  admis- 
sion he  was  semiconscious,  stuporous,  confused,  disoriented, 
anxious  in  a  dull  sort  of  way,  talking  about  his  expectation  of 
"a  sailor  with  a  card."  Speech  was  intelligible,  though  frag- 
mentary and  infrequent.  The  man  obeyed  commands  but 
gave  no  replies  to  questions.  The  mental  processes  were 
slow  and  impaired. 

According  to  Ballard,  we  have  here  a  case  of  epileptic  con- 
fusion, eight  months  after  the  initial  concussion.  This  par- 
ticular attack  ceased  three  days  later,  leaving  amnesia  for  the 
attack  and  a  certain  amount  of  mental  retardation.  The 
man  was  not  epileptic  in  temperament  and  his  personal  and 
family  history  proved  negative. 

Case  84.     (Ballard,  19 17.) 

A  soldier  was  buried  in  a  mine  explosion,  October,  191 5, 
and  for  several  days  thereafter  was  unconscious  or  semi- 
conscious. He  emerged  deaf  and  subject  to  stammering  and 
a  condition  termed  "neurasthenic."  The  stammering  was 
soon  replaced  by  mutism,  which  lasted  several  weeks.  The 
mutism  was  then  supplanted  by  epileptic  fits. 

He  was  observed  by  Ballard  in  a  dreamlike,  disoriented 
and  inaccessible  state,  in  which  he  was  anesthetic  to  pin 
pricks,  lay  awestruck,  dumbly  following  with  his  finger  hal- 
lucinatory airplanes.  Flexibilitas  cerea  was  also  shown  at 
this  time. 

Next  day  he  emerged  from  the  dreamlike  state  with  men- 
tal processes  somewhat  slowed,  disorientation  for  time,  am- 
nesia for  the  attack,  memory  disturbance  and  a  return  of 
the  stammer.  On  the  next  day  following,  all  these  symp- 
toms had  disappeared  except  amnesia  for  the  attack.  An- 
other spell  of  epileptic  fits  occurred  later.  It  seems  that  the 
man  had  had  a  convulsion  thirteen  years  before  and  occa- 
sional convulsions  since.  In  fact,  he,  seven  years  before, 
had  had  what  was  called  "a  stroke  "  and  residuals  of  a  slight 
hemiplegia  were  still  present.  (There  is  no  statement  in  the 
case  report  relative  to  syphilis.) 


112  EPILEPTOSES 


Emotion ;  shell  fire :  Epileptic  equivalents. 


Case  85.     (MoTT,  January,  1916.) 

A  man,  19,  suffered  from  shock  due  to  emotional  stress  and 
shell  fire.  He  had  terrifying  dreams.  After  a  short  time, 
he  developed  paroxysmal  attacks  of  maniacal  excitement. 
Just  before  the  first  attack  he  had  been  helping  in  the  kit- 
chen, lay  down  on  his  bed,  went  to  sleep,  woke,  startled, 
flushed,  and  sweating,  and  made  for  the  door  as  if  terrified. 
He  remained  in  this  state  as  if  suffering  from  hallucinations 
of  sight  and  hearing,  and  without  ability  to  recognize  his 
wife,  the  doctors,  or  the  Sisters.  When  two  strangers  in 
uniform  came  in  to  observe  him,  the  adjutant  became  vio- 
lent, as  if  the  uniforms  had  started  terror  anew.  The  attacks 
lasted  from  a  few  hours  to  a  few  days,  coming  on  suddenly, 
without  apparent  cause.  One  day  he  tried  to  get  over  the 
wall  of  the  playground.  He  came  back  and  buried  his  head 
in  his  hands.  Major  Mott  spoke  to  him,  whereupon  he  got 
up,  looking  terrified,  made  for  the  door,  and  four  orderlies 
were  required  for  his  restraint.  At  Napsbury  Hospital,  to 
which  he  was  sent,  he  made  a  complete  recovery. 

Mott  suggests  that  we  are  dealing  with  a  psychic  equiv- 
alent of  epilepsy. 

Re  epileptic  equivalents,  compare  notes  from  Lepine  under 
58  and  59. 


IV.   PHARMACOPSYCHOSES 
(THE  ALCOHOL,   DRUG,  AND  POISON  GROUP) 


Pathological  intoxication. 


Case  86.     (Boucherot,  1915-6.) 

A  Territorial  infantryman,  aged  37,  was  in  the  habit  of 
drinking  a  good  deal  without  getting  drunk,  and  at  the  front 
drank  a  good  deal  of  bad  brandy.  He  had  just  taken  a  con- 
siderable quantity  when  his  regiment  got  the  order  to  charge. 
The  charge  was  hardly  over  when  the  man  became  greatly 
excited  and  hallucinated.  He  thought  he  was  surrounded  by 
Germans  and  tried  to  transfix  his  comrades  with  the  bayonet. 
Howling  and  struggling  he  was  carried  to  the  rear. 

He  was  soon  brought  to  the  asylum  at  Fleury  after  howl- 
ing all  night  and  seeing  the  Boches  and  animals  fighting 
among  themselves.  His  hands  and  tongue  were  tremulous 
and  there  were  cramps  in  the  calves  of  his  legs.  On  the  6th 
he  expressed  astonishment  to  find  himself  in  hospital  and 
was  found  to  have  but  slight  memory  of  what  had  happened. 
He  remembered,  however,  that  he  had  tried  to  kill  his  com- 
rades. With  the  deprivation  of  alcohol  he  became  rapidly 
normal  and  was  sent  back  to  the  dep6t  in  a  few  days. 

Re  alcoholism  under  army  conditions,  Lepine  remarks  that 
alcohol  has  played  in  this  war  a  role  analogous  to  that  of 
malaria  in  the  epidemiology  of  some  countries.  Many  of 
the  victims  are,  to  start  with,  unbalanced  subjects  and 
detraques  who  are  hereditary  alcoholics.  Alcoholism,  accord- 
ing to  Lepine,  dominates  the  pathology  of  the  interior  and 
has  a  marked  bearing  upon  conditions  at  the  front.  In 
fact,  alcoholism  would  have  been  disastrous  in  France  had 
not  measures  been  taken  against  it ;  measures  still  insufficient 
(191 7).  More  than  one- third  of  6000  cases  studied  by  Lepine 
during  three  years  have  shown  alcohol  as  a  sole  or,  at  all 
events,  principal  cause  of  the  difficulty.     It  would  be  within 

113 


114  PHARMACOPSYCHOSES 

reason  to  state,  according  to  Lepine,  that  if  we  throw  in 
cases  in  which  alcohoHsm  was  a  partial  factor,  more  than 
half,  or  even  more  than  two-thirds,  of  the  mental  cases  had 
been  strongly  influenced  by  alcohol.  Lepine  thinks  there 
may  be  effects  like  those  of  anaphylaxis.  Certainly,  the 
startling  and  sudden  effects  in  so-called  pathological  intoxi- 
cation, as  in  Case  86,  suggest  the  critical  and  vehement 
effects  seen  in  the  sensitized  anaphylactic  subject. 


PHARMACOPSYCHOSES  II5 


PHASES   OF  WAR  PSYCHIATRY  IN  FRANCE 


I.   Antebellum  phase  of  Psychiatric  Neglect:  Groundless  fear  that 
recruiting  would  be  disorganized  by  psychiatric  sifting  processes. 

II.   Phase  of  Alcoholism  of  Mobilization:  Hospitals  unprepared. 

III.  Phase  of  the  Marne:  Alcoholism  restrained  by  law;  psychoses  few; 

psychiatrists  optimistic. 

IV.  Phase  of  Trench  Warfare:  Overemotionality;  and  of  High  Ex- 

plosives (January,  1915);    now  psychiatric  services  were  syste- 
matically established  along  evacuation  lines. 

V.  Phase  of  Systematic  War  Psychiatry:  Filterwise  system  of 
management  (a)  near  trenches,  (6)  in  main  body  of  army,  (c)  on 
evacuation  lines,  {d)  special  hospitals. 

Chiefly  from  data  of  Chavigny,  19 15. 


Chart  4 


Il6  PHARMACOPSYCHOSES 


Pathological    intoxication:       criminal   prosecution 
stopped. 


Case  87.     (LoEWY,)  1915-) 

An  orderly,  in  private  life  a  teacher,  one  day  about  noon- 
time, when  going  on  duty,  called  the  commanding  officer  to 
account  because  he  (the  orderly)  had  had  to  wait.  He  said 
he  had  been  ordered  to  come  at  two  o'clock  and  it  was  al- 
ready long  thereafter!  He  was  severely  reprimanded  but 
addressed  a  number  of  the  officers  present  with  questions 
having  no  relation  to  military  service.  In  fact,  he  seemed 
to  have  forgotten  entirely  that  he  was  on  military  service. 

This  was  the  more  remarkable  as  the  teacher-orderly  had 
many  times  distinguished  himself  upon  dangerous  patrol 
expeditions  and  in  critical  situations,  winning  the  confidence 
of  his  superiors  and  the  likelihood  of  promotion  to  corporal. 
He  had  been  a  discreet,  earnest,  and  clever  soldier, 

Loewy  observed  him  during  this  affair  and  noticed  that 
he  did  not  by  language  or  movement  suggest  intoxication  or 
hilarity  but  merely  a  certain  excitement.  He  was  entirely 
oriented  for  time,  place  and  person,  and  his  outward  be- 
havior was  correct  enough  except  for  his  military  rank. 

Sent  to  his  quarters  near  by,  he  gave  the  impression  to  his 
immediate  superior  officer  of  deep  drunkenness.  He  mur- 
mured something  and  soon  fell  into  a  deep  sleep.  After 
waking,  he  had  an  almost  complete  amnesia,  knowing  only 
that  something  disagreeable  had  transpired.  He  remem- 
bered that  he  had  been  offered  several  little  glasses  of  cognac 
brandy  by  a  comrade,  and  that  he  had  drained  them  off 
quickly  before  going  on  duty.  He  said  that  he  had  never 
drunk  cognac  before,  and  in  fact  had  drunk  nothing  for  a 
long  time. 

The  diagnosis  of  pathological  intoxication  was  made,  and 
the  soldier  was  thereby  cleared  of  his  dangerous  situation; 
a  criminal  prosecution  was  not  instituted.  He  thereafter 
behaved  with  entire  sobriety  and  modesty,  and  he  achieved 
his  corporalcy  and  later  became  file  leader. 


PHARMACOPSYCHOSES  1 1 7 

Desertion   in   alcoholism   may  deserve   the   term 
**  pathological."     Case  of  fugue. 


Case  88.     (Logre,  July,  191 6.) 

A  "deserter"  said:  "I  went  because  I  drank  a  glass.  I 
just  went,  comme  ca,  without  any  motive."  He  was  some- 
what feebleminded  and,  in  explaining  the  impulsivity  of  his 
act,  he  added:  " I  went  like  a  broken-down  beast.  I  walked 
straight  ahead,  without  knowing  where  I  was  going  and  if  I 
had  been  going  to  be  killed,  it  would  have  been  all  the  same 
to  me."  He  could  not  that  afternoon  remember  very  well; 
but  next  morning,  after  having  slept,  he  regained  full  con- 
sciousness. He  said  that  he  then  found  himself  in  a  field 
near  a  cemetery.  He  had  carried  his  gun  and  equipment 
with  him,  but  had  lost  them  somewhere,  and  from  a  military 
point  of  view,  his  desertion  was  complicated  by  loss  of  effects. 
On  coming  to,  he  said  to  himself,  "Where  am  I?  How 
foolish  after  fifteen  months  in  the  line!  Probably  I  have 
deserted  again."  In  fact,  he  had  a  month  before  left  his 
post  under  exactly  the  same  conditions  in  the  midst  of  a 
period  of  alcoholic  excitement. 

This  alcoholic  fugue  is  typical :  drunkenness,  impulsive  and 
subconscious  ambulatory  automatism,  with  partial  amnesia, 
disorientation,  with  mislaying  of  objects,  followed  by  sleep 
and  immediate  return  to  normality. 

Re  fugue,  see  discussion  under  Cases  58  and  59.  The 
French  military  code  cannot  excuse  victims  of  fugue  even 
though  executed  in  a  quite  unconscious  state,  if  the  fugue 
is  due  to  alcohol.  There  was  a  certain  procursive  sugges- 
tion in  the  fugue  of  Case  88,  who  went  "like  a  broken-down 
beast,"  straight  ahead,  without  knowing  where  he  was  going. 


1 1 8  PHARMACOPS YCHOSES 


Alcoholism:  Amnesia  experimentally  reproduced. 


Case  89.     (Kastan,  January,  1916.) 

February  15,  191 5,  a  German  soldier  drank  beer  in  the 
canteen  and  at  roll-call  appeared  tipsy.  He  then  went  to 
bed,  but  rose  an  hour  later  to  go  to  town.  A  quarter  of  an 
hour  later,  he  went  to  a  clerk's  house  and  asked  for  paper, 
on  the  ground  that  the  next  day  he  was  going  to  march  to 
Warsaw.  The  clerk  gave  him  no  paper,  which  he  then  tried 
to  get  by  force.  A  policeman  arrested  him  and  he  said, 
"You  just  wait,  lame  dog!"  Upon  examination  he  denied 
that  he  had  ever  been  guilty  of  any  crime  but  had  been  in 
institutions  on  account  of  delirium.  In  point  of  fact,  this 
man  had  grown  up  in  very  bad  surroundings,  amongst  quar- 
rels and  disputes  of  his  parents,  who  kept  a  disorderly  house. 
At  19  he  had  been  convicted  of  incest.  He  finally  admitted 
having  been  convicted  for  rape.  It  was  found  that  he  had 
once  run  out  into  the  front  trenches ;  had  been  removed  by  an 
advance  guard  to  a  stable,  and  then  wondered  why  he  was 
not  in  school.  He  described  a  number  of  attacks  of  delirium 
although  he  had  not  drunk  more  than  moderately. 

He  was  given  an  experimental  dose  of  50  c.c.  of  alcohol, 
and  in  ten  minutes  became  excited,  tried  to  get  out  of  bed, 
attacked  other  patients  without  reason,  and  was  able  to 
speak  neither  spontaneously  nor  in  response  to  questions. 
In  a  period  of  two  hours  he  became  clear  and  asked  what 
the  trouble  was.     He  knew  only  that  he  had  taken  alcohol. 

Re  the  experimental  excitement  produced  in  Kastan's  case 
by  the  exhibition  of  alcohol,  it  is  of  note  that  Berard  has  been 
much  impressed  by  the  agitation  that  surgical  cases  of  alco- 
holism undergo  when  anesthetized.  It  may  be  that  the  an- 
esthetics act  similarly  to  the  experimental  alcoholism  of 
Kastan's  case.  According  to  Berard,  these  phenomena  of 
the  anesthetized  wounded  (who  are  men  recently  evacuated 
from  the  front  and  other  hospital  cases)  are  of  larv^al  alcohol- 
ism brought  out  by  the  anesthesia.  Berard  wonders  whether 
rum  issues  at  the  front  are  at  all  responsible  therefor. 


PHARMACOPSYCHOSES  II9 

Desertion,  drunk.     Contributory  factors. 


Case  90.     (Kastan,  January,  1916.) 

Gottlieb  S.  left  the  barracks,  January  25,  1915,  met  friends 
and  drank  with  them,  remaining  all  night  in  the  railway 
restaurant  and  waiting  room.     He  was  promptly  arrested. 

According  to  the  patient,  he  had  always  drunk  a  good  deal 
and  had  once  fallen  from  his  horse  in  the  campaign,  and  be- 
come unconscious.  After  this  fall,  he  said  he  had  been  able 
to  stand  less  alcohol  than  before. 

There  is  doubt  as  to  the  syphilis  of  Gottlieb.  He  said  he 
had  been  infected  once,  but  his  further  statement  that  he 
had  six  relapses  is,  of  course,  questionable.  As  to  the  hypoth- 
esis of  feeblemindedness,  it  appears  that  in  childhood  he 
had  learned  badly  and  had  been  a  stammerer.  He  had  been  a 
herdsman,  and  after  that  a  laborer.  He  finally  became  a 
travelling  man  for  a  specialty  photographer. 

He  had  previously  been  convicted  of  an  embezzlement, 
brawling,  and  breach  of  the  peace. 

As  to  his  military  crime,  he  said  he  had  been  celebrating 
the  emperor's  birthday  the  last  three  days,  being  urged  on  by 
acquaintances  and  drinking  whiskey.  He  was,  in  fact,  on  a 
spree  and  did  not  eat  properly.  He  had  met  a  student  In 
the  railway  station  and  had  forgotten  all  about  his  military 
service.  He  remembered  having  spoken  with  the  waiter, 
remembered  telling  the  student  that  he  was  going  to  commit 
suicide,  and  the  student  had  drunk  seltzer  with  him.  Jan- 
uary 29,  he  for  some  reason  drank  no  more,  and  then  it 
occurred  to  him  that  he  ought  to  go  back  to  duty.  He 
remembered  that  he  was  easily  led  astray.  He  had  once 
thought  of  becoming  a  tanner  but  had  been  dissuaded  from 
the  trade  because  of  its  bad  smell. 

The  analysis  of  this  case  must  consider,  first,  syphilis. 
Supposing,  however,  that  this  hypothesis  is  not  sub- 
stantiated by  laboratory  findings,  the  hypothesis  of 
feeblemindedness  might  well  be  raised.  It  seems  pos- 
sible, if  not  probable,  that  this  patient  was  in  the 
subnormal  group,  lying  between  normality  and  feeble- 


I20  PHARMACOPSYCHOSES 

mindedness  proper.  The  value  of  mental  tests  would 
here  be  extreme.  There  seems  to  be  no  evident  epi- 
lepsy, and  the  majority  of  the  phenomena  can  perhaps 
best  be  explained  by  alcoholism.  Possibly  the  case  is 
one  of  so-called  pathological  intoxication.  The  pa- 
tient's own  story  that,  although  he  had  been  always 
subject  to  drink,  he  had  been  less  tolerant  of  alcohol 
since  a  fall  from  his  horse,  seems  to  be  entirely  consist- 
ent with  the  post-traumatic  history  of  numerous  cases, 
so  that  it  would  hardly  be  wise  to  consider  that  alcohol 
accounts  for  the  whole  story.  We  must  raise  then  in 
succession  the  hypothesis  of  syphilis,  feeblemindedness, 
alcoholism,  and  coarse  brain  disease,  bearing  in  mind 
also  early  stammering.  As  to  the  utilization  of  such  a 
man,  it  would  appear  that  a  supervision  of  him  with 
absolute  countermanding  of  alcohol  in  view  of  the  de- 
crease in  tolerance  of  alcohol  since  the  fall  from  his 
horse  might  perhaps  preserve  this  man  for  some  form 
of  military  service. 

Re  German  and  French  war  alcoholism,  Soukhanofif  re- 
marks that  the  conditions  in  these  countries  were  in  strong 
contrast  to  those  in  Russia.  In  Russia  there  was  a  great 
decrease  in  the  number  of  cases  of  acute  alcoholic  psychosis; 
particularly  at  the  time  of  mobilization,  there  were  few  cases 
of  alcoholic  psychosis.  He  says  that  during  the  Russo- 
Japanese  war,  alcoholic  psychoses  constituted  a  third  of  all 
the  mental  cases  observed.  This  figure  corresponds  with 
that  quoted  above  from  Leplne  (see  under  Case  86).  Souk- 
hanoff,  writing  In  191 5,  had  not  observ^ed  personally  a  single 
case  of  alcoholic  psychosis.  Incidentally,  the  number  of 
cases  of  psychosis  in  the  Russian  army  had  remained  in 
general  small. 


PHARMACOPSYCHOSES  121 


Desertion  by  mild  alcoholic  dement. 


Case  91.     (Kastan,  January,  1916.) 

Emil  S.  made  a  number  of  statements  when  he  came  for 
examination.  He  had  once  had  a  treatment  by  injections. 
Both  his  mother  and  his  grandmother  had  been  Insane.  He 
said  that  his  brother  was  an  officer  In  the  navy,  but  this 
statement  was  found  to  be  false. 

According  to  his  story,  he  had  lost  touch  with  his  troop  at 
the  end  of  September,  1914,  and  had  lived  in  several  lodgings 

In  T up  to  October  19,  when  he  was  arrested.     He  said 

that  he  did  not  know  that  a  man  who  had  lost  touch  with  his 
troop  had  to  report. 

A  week  after  his  arrest,  S.  entered  a  shop  and  asked  for 
coffee,  saying  that  he  had  a  furlough  of  24  hours  and  wanted 
cake  for  his  comrades.  He  said  he  was  the  owner  of  an 
estate  and  would  send  a  roebuck  for  the  cakes.  The  shop- 
man gave  him  cakes  to  the  value  of  one  mark.     Bystanders 

said  that  he  had  been  lodging  In  T for  about  two  weeks. 

It  seems  that  he  had  told  his  landlady  that  a  city  official 
had  quartered  him  upon  her  and  that  he  was  on  furlough. 
He  went  away  In  the  morning  and  came  back  In  the  evening. 
He  had  written  to  a  bank  of  which  he  had  once  been  a  repre- 
sentative, asking  for  money.  One  night  he  had  lodged  with 
another  landlady,  being  given  a  meal,  and  he  had  there 

stated  that  he  was  in  the  City  of  T on  duty  and  that  his 

horse  was  in  the  barracks.  He  offered  a  thousand  marks 
for  his  board  and  lodging. 

At  another  lodging  he  had  given  himself  out  as  a  courier. 
In  fact,  the  letter  to  the  above-mentioned  bank  had  been 
signed  "Otto  S.,  Land-owner,  at  present,  courier." 

"If  I  do  not  revoke  this  in  person  or  by  writing  on 
January  i,  1915,  I  beg  you  to  pay  to  Mr.  and  Mrs.  M. 

of  T ,  one  thousand  marks  and  deduct  it  from  my 

balance. 

"  This  Is  to  be  considered  as  my  last  will.  As  witness : 
present:  Joseph  B." 

The  letter  was  addressed  "To  the  direction  of  Commercial- 
Counsellor  P ."     There  was  no  stamp  on  the  letter. 


122  PHARMACOPSYCHOSES 

A  second  letter  reads: 

"Honored  Sir,  Commercial  Counsellor: 

I  beg  you  to  send  by  return  mail  to  the  address  given 
below  1000  marks,  and  deduct  this  amount  from  my 
account.  I  have  been  in  Russia.  Well,  things  are 
moving  now.  Thank  God,  we  have  reached  the  point 
we  have.  Write  me  please  more  in  detail  about  my 
property  and  estate  and  give  me  your  very  valuable 
advice. 

With  best  regards  to  your  esteemed  wife,  I  remain 
Sincerely  and  respectfully  yours. 

Otto  S.,   at  present  courier, 

otherwise,  land-owner." 

As  for  this  Commercial-Counsellor  P.,  P.'s  son  stated  that 
his  father  had  been  dead  for  three  years  and  a  half. 

S.  gave  himself  out  in  T as  a  land-owner,  falsifying 

his  name,  asking  for  beer  to  the  amount  of  a  mark  a  day, 
borrowing  from  his  landlady  ten  marks,  paying  nothing,  but 
remaining  on  friendly  terms  with  the  landlady  and  her  women 
lodgers,  making  a  contract  with  a  superintendent  ostensibly 
for  his  estate,  and  borrowing  money  from  him. 

Observed  in  the  clinic,  he  said  he  was  a  bank  represen- 
tative and  had  been  very  nervous  since  being  divorced  in 
191 1.  The  divorce  was  due  to  his  wife's  adultery.  Some- 
times he  would  not  know  really  what  he  was  doing,  once  even 
tried  to  shoot  himself,  and  again  once  threw  a  burning  lamp 
into  his  wife's  face  without  knowing  it. 

He  had  gone  to  the  City  of  T without  furlough  in 

October  because  others  used  to,  too.  Only  five  days  later 
had  he  noticed  that  his  troop  was  no  longer  there;  and  upon 
inquiring  about  the  troop  he  could  find  nothing  as  to  its 
whereabouts. 

He  had  been  a  heavy  drinker  and  was  always  somewhat 
intoxicated,  which,  according  to  the  patient,  made  him  forget 
everything.  He  had  drunk  20  glasses  of  beer  and  liquor 
daily.     He  wrote  to  P.  because  he  knew  his  father. 

As  for  the  frauds,  he  said  he  knew  nothing  about  them. 
He  did  not  know  even  the  baker  from  whom  he  had  gotten 
the  cakes.     In  fact,  he  had  been  drunk  the  whole  day  long. 


PHARMACOPSYCHOSES  123 

He  said  that  he  had  learned  badly  in  school  and  had  not 
passed  any  examinations.  In  active  service  he  had  already 
been  convicted  of  drunkenness  once.  Referring  to  his  treat- 
ment by  injections,  he  said  he  would  rather  be  dead.  He 
had  only  sought  diversion  in  looking  over  estates.  Both  his 
ability  to  reckon  and  his  memory  had  suffered  greatly.  He 
and  another  patient  eloped  from  the  clinic  one  day  but  were 
captured  a  few  hours  later. 

Remarks:  Details  are  lacking  as  to  the  physical  and 
laboratory  side  of  this  case.  On  the  whole,  there  ap- 
peared to  be  no  convincing  features  of  paresis  or  cere- 
brospinal syphilis.  The  phenomena  are  very  possibly 
in  part  alcoholic.  There  appeared  to  be  no  sensory 
disorders,  and  in  particular  no  hallucinations.  The  in- 
tellectual disorder  is  chiefly  amnestic.  There  is  little 
or  no  evidence  of  emotional  abnormality.  The  curious 
conduct  seems  hardly  to  indicate  a  primary  disorder  of 
will.  The  main  feature  psychologically  appears  to  be 
amnesia  coupled  with  an  inability  to  reckon.  To  be 
sure,  the  letters  are  written  externally  in  sufficiently 
good  form;  the  amnesia  does  not  appear  to  extend  to 
details.  It  is  a  question  of  whether  the  disorientation 
which  one  suspects  is  not  merely  amnestic.  On  the 
whole,  however,  it  would  appear  that  there  must  have 
been  at  various  times  disorder  of  consciousness,  as  in- 
deed is  indicated  by  the  patient's  own  account  of  his 
ignorance  of  the  cake-roebuck  episode. 

Dismissing  the  hypothesis  of  a  syphilitic  dementia, 
we  might  cling  to  that  of  alcoholic  dementia  more  or 
less  punctuated  by  acute  alcoholism.  Yet  it  is  also 
possible  that  the  patient  was  actually  somewhat  feeble- 
minded; this  would  be  consistent  with  his  own  state- 
ment. The  question  might  arise  whether  this  soldier 
could  have  been  excluded  by  careful  psychiatric  ex- 
amination before  entering  service.  It  would  seem  that 
a  knowledge  of  the  insanity  of  the  mother  and  grand- 
mother, and  an  inspection  of  school  records,  if  available, 
—  to  say  nothing  of  the  episodes  which  may  or  may 
not  have  been  accurately  related,  between  himself  and 
his  afterwards  divorced  wife  —  would  have  sufificed  to 
throw  doubt  upon  the  military  effectiveness  of  this 
man.  We  know  also  that  he  had  already  been  con- 
victed of  drunkenness  on  military  service  before  the 
episodes  mentioned. 


124  PHARMACOPSYCHOSES 

Desertion  by  alcoholic.     Contributory  factors. 


Case  92.     (Kastan,  January,  1916.) 

Carl  B.  was  a  soldier  about  whom  the  captain  thought  that 
his  intellectual  power  had  been  weakened  by  drink.  An 
inquiry  after  arrest  showed  that  he  had  been  odd  also  at 
home.  He  had  once  been  sued  for  perjury,  but  the  suit  had 
been  stopped  for  lack  of  evidence.  He  had  been  several 
times  convicted  of  drunkenness.  It  appears  that  on  March 
30,  191 5,  after  mounting  guard,  he  said  nothing  and  went 
home,  remaining  at  home  until  the  next  day  and  then  re- 
turned to  the  guardhouse  in  the  street-car.  He  declared, 
this  time,  that  the  non-commissioned  officer  had  given  him 
permission  to  leave,  although  this  statement  was  not  correct. 

Again,  on  April  6,  B.  was  about  to  leave  the  quarters, 
but  the  surgeon,  finding  him  drunk,  kept  him  back.  He 
did  not  go  home  that  night,  and  the  next  day  when  he  was 
wanted  at  the  hearing,  he  could  be  found  only  in  the  after- 
noon. He  replied  confusedly  and  somewhat  irrelevantly 
to  the  questions  asked.  On  arrival  at  the  clinic  he  was  in 
tears  and  much  depressed.  Given  50  grams  of  alcohol,  he 
became  somewhat  livelier.  Upon  examination,  his  percep- 
tions were  found  diminished;  he  felt,  he  stated,  a  cracking 
and  crackling  in  his  neck.  In  his  cell  he  had  felt  as  if  spar- 
rows were  roosting  in  his  face;  he  had  heard  voices  and  seen 
pictures,  and  had  not  known  what  he  was  doing.  He  as- 
serted his  innocence,  blaming  his  imprisonment  for  all  his 
troubles.  He  had  been  in  the  habit  of  drinking  three 
liqueurs  and  two  glasses  of  beer  a  day.  He  had  been  draw- 
ing a  pension  since  a  fall  from  a  scaffold. 

A  sister  had  suffered  from  continual  headaches.  The 
patient  himself  had  three  sickly  children  and  ten  of  his 
children  were  dead;    there  were  also  two  premature  births. 

The  analysis  of  this  case  would  clearly  show  the 
benefit  of  considering,  first,  the  hypothesis  of  syphilis. 
Not  only  is  the  history  of  his  children  suggestive,  but 
the  impairment  of  mind  noted  by  the  captain  as  due  to 
alcohol  may  very  possibly  be  syphilitic  in  origin.     Ex- 


PHARMACOPSYCHOSES  1 25 

amples  in  division  he  could  not  solve,  and  it  is  a  ques- 
tion whether  his  leaving  guardmount  is  not  in  part 
related  to  disorientation  for  time.  There  appears  to 
be  no  evidence  of  feeblemindedness  and  none  of  epi- 
lepsy (though  a  sister  suffered  from  continual  head- 
aches). Alcohol  may  account  possibly  for  the  entire 
picture  and  is  particularly  consistent  with  the  false 
voices  and  figures,  the  sparrows  in  the  face,  and  the 
sensations  in  neck  and  the  tickling  in  the  ears.  It  is 
possible,  also,  that  intolerance  to  alcohol  had  set  in 
since  the  fall  from  the  scaffolding  for  which  a  pension 
was  being  received.  It  does  not  appear  necessary  to 
consider  any  further  of  the  groups  of  mental  disease. 
Syphilis,  alcohol,  and  a  post-traumatic  brain  condition, 
all  may  play  a  part.  Alcohol  is  able  probably  by  itself 
to  produce  a  number  of  these  symptoms,  and  these  al- 
coholic symptoms  would  be  probably  the  more  readily 
produced  in  virtue  of  the  post- traumatic  intolerance 
that  we  may  assume. 


126  PHARMACOPSYCHOSES 

A  disciplinary  case  :  Alcoholism. 


Case  93.     (Kastan,  January,  19 16.) 

A  German  soldier,  brought  up  for  examination  for  dis- 
obedience and  insubordination  with  intoxication,  was  found 
already  to  have  been  convicted  33  times  of  a  variety  of 
crimes.  Once  he  had  drunk  a  bottle  of  shoemaker's  polish, 
evidently  with  suicidal  intent. 

In  the  canteen  he  had  assaulted  superior  officers  and  tried 
to  strike  a  sergeant.  He  said  he  had  been  attacked  by  the  ser- 
geant and  pushed  into  a  cell,  whereupon  he  had  lost  his  mind. 

He  came  from  a  family  of  drunkards,  and  had  been  him- 
self very  alcoholic  formerly.  On  the  day  in  question,  how- 
ever, he  had  drunk  very  little.  According  to  his  account, 
he  had  fits  of  this  sort  if  any  one  injured  him.  He  was 
amnestic  and  had  forgotten  his  previous  convictions.  Any- 
thing he  might  have  done,  he  said,  had  happened  a  long 
time  ago,  in  his  youth.  For  example,  concerning  a  theft,  he 
said  that  it  was  merely  that  he  had  fallen  into  some  Christ- 
mas trees  and  stuck  fast  there,  and  no  one  wanted  to  be 
paid.     Tremors  of  hands,  feet,  head.     Analgesia  of  thorax. 

Re  alcoholism  and  disciplinary  cases,  we  find  alcoholism 
bulking  large  in  Lepine's  account  of  military  delinquency. 
Fugue  subjects  are  not  infrequently  alcoholic.  Minor  dis- 
obedience is  also  often  alcoholic.  Acts  of  violence  are  char- 
acteristically alcoholic,  or  executed  by  subjects  with  heredi- 
tary alcoholic  taint.  (Such  acts  were  in  France  especially 
common  before  the  anti-absinthe  law  in  19 15.)  Alcoholic 
episodes  and  impulses  often  culminate  in  arson.  No  doubt, 
espionage  employs  alcoholism  for  a  portion  of  its  technique, 
though  delusional  mystics  and  subnormal  hypersuggestibles 
are  more  often  the  purveyors  of  information  to  the  enemy. 
The  theft  list,  also,  shows  its  share  of  alcoholics.  Alcoholics 
are  less  common  amongst  those  who,  contrary  to  rules, 
assume  shoulder-straps  or  other  decorations.  Here  the  sub- 
normals and  victims  of  imbalance,  as  well  as  the  drug  cases, 
are  more  likely  to  figure  if  the  matter  is  psychiatric  at  all. 


PHARMACOPSYCHOSES  1 27 

Remarks  upon  an  atrocity. 


Case  94.     (Kastan,  January,  1916.) 

April  15,  1 91 5,  a  German  soldier  went  with  three  comrades 
to  a  farm,  to  select  a  sheep  for  slaughter;  they  were  obliged 
to  go  to  three  farms.  The  man  carried  a  revolver  and  cart- 
ridges in  his  pocket.  He  threatened  the  farmer  that  he  met 
with  this  revolver,  and  desired  to  rape  the  farmer's  daughter. 
He  was  very  drunk,  and  said  to  the  non-commissioned  officer 
who  was  called  in  at  the  time,  "You  have  served  only  a  year 
longer  than  I  have."  He  staggered,  struck  violently  with  his 
hand  at  the  sergeant,  and  gave  insolent  replies. 

He  had  already  choked  the  peasant's  daughter,  scratched 
her  face,  and  bitten  her  fingers,  hand  and  arm.  She  could 
not  run  away  as  she  was  lame.  The  soldier  held  the  revolver 
to  her  face  and  shot  it  ofT  several  times,  offered  sex  assault, 
scratched  her  feet  with  his  spurs,  and  tried  to  twist  her  neck. 
The  non-commissioned  officer  threatened  to  shoot  him,  and 
he  then  became  still.  He  said  to  the  first-lieutenant  before 
whom  he  was  taken,  that  he  would  do  anything  but  allow 
himself  to  be  beaten,  and  at  this  moment  moved  his  arms 
about  in  the  air,  and  bloody  foam  came  from  his  mouth. 
The  first-lieutenant  previously  had  always  thought  him  to 
be  normal  except  for  a  strange  flicker  and  unrest  of  the  eyes. 
There  was  a  history  that  he  had  already  once  attacked  a 
servant  girl.  The  man  had  amnesia  for  the  affair,  only 
remembering  how  the  non-commissioned  officer  had  come  on 
a  white  horse.  He  remembered  nothing  about  the  peasant 
and  the  girl.  He  said  that  he  had  been  given  to  earache  on 
the  right  side  in  winter.  There  was  a  history  of  his  having 
fallen  from  a  tree  in  childhood,  becoming  unconscious.  He 
had  been  a  sufficiently  good  scholar  up  to  the  second  class 
in  school.     He  had  been  an  excellent  soldier. 


128  PHARMACOPSYCHOSES 


Alcoholism:  Atrocity. 


Case  95.     (Kastan,  January,  1916.) 

September  15,  1914,  a  German  soldier  was  missed.  He 
had  said  that  he  wanted  to  get  to  the  enemy  quickly,  and  that 
he  was  going  to  march  alone  against  the  Russians.  A  shot 
was  fired  that  night  by  this  soldier,  on  the  ground  that  he  had 
been  insulted  by  a  civilian,  although  no  civilian  was  present. 

September  21,  a  farmer  in  a  wagon  reached  a  farm,  where 
he  found  the  soldier  aiming  at  a  woman.  He  fired,  wounded 
the  woman  severely,  and  jumped  on  the  farmer's  wagon  and 
rode  'off  with  him.  It  seems  that  the  soldier  had  come  to 
the  farm  at  noontime  and  accused  the  woman  of  treachery, 
ordering  her  to  come  with  her  husband  to  a  certain  farmhouse, 
where  she  should  be  placed  against  the  wall  and  be  shot.  The 
soldier  had  shot  her  and  wounded  her  husband  also.  Ac- 
cording to  the  woman,  the  idea  was  to  take  revenge  because 
she  had  denounced  certain  persons  as  spies. 

He  was  arrested  during  the  night,  and  told  how  he  had  left 
his  troop  because  he  could  not  get  at  the  enemy.  He  had 
been  informed  that  there  were  spies  who  ought  to  be  shot; 
there  had  been  talk  in  a  certain  inn  about  it.  He  did  not 
know  he  had  wounded  the  husband,  and  he  only  wanted  to 
give  that  dangerous  woman  a  piece  of  his  mind. 

After  wounding  the  woman,  he  had  given  himself  no 
further  thought  about  her,  but  had  gone  to  partake  of  the 
holy  sacrament  at  the  pastor's.  He  then  had  drunk  another 
glass  of  beer  and  gone  to  bed.  He  was,  in  fact,  still  drunk 
at  the  time  of  arrest.  He  had  not  been  aware  that  he  would 
be  punished  for  the  crime  of  going  alone  against  the  Russians. 

Some  days  later,  he  wrote  that  he  did  not  intend  to  kill  the 
woman,  that  he  had  been  drunk  at  the  time  and  was  always 
a  bad  man  when  drunk;  that  he  had  other  times  when  he 
absented  himself  from  home  for  days  when  drunk.  He  had 
had,  he  said,  a  number  of  attacks  of  delirium,  in  which  he 
had  seen  animals.  At  one  time,  he  had  fallen  on  his  head. 
On  the  day  in  question,  he  had  drunk  i|  litres  of  liquor.  He 
was  remorseful  for  his  deed. 


PHARMACOPSYCHOSES  1 29 

A  disciplinary  case :  Alcoholism ;  amnesia. 


Case  96.     (Kastan,  January,  191 6.) 

A  German  soldier,  New  Year's  Eve,  1915,  got  away  from 
his  company,  drank  whiskey,  and  came  back  drunk.  He 
bothered  his  comrades  so  that  the  non-commissioned  officer 
had  to  call  for  help;  whereupon  the  soldier  said,  "A  man  who 
comes  on  late  and  hasn't  been  in  much,  hasn't  much  to  say. 
If  it  is  a  non-commissioned  officer,  I  shall  hit  him  in  the 
snout."  The  officer  kept  talking  to  him  kindly  but  he  cried 
'' Half  s  Maul,  you  crooked  .  .  .  !  "  He  staggered  up  to  the 
lieutenant  without  saluting,  but  at  a  slight  push  fell  prone 
into  the  straw. 

It  transpired  that  the  man  had  not  been  intoxicated 
enough  to  lose  all  control  of  himself.  He  did  not  remember 
anything  about  what  he  had  done;  he  had  drunk  a  half- 
bottle  of  rum  during  the  evening.  There  was  a  demonstrable 
lack  of  memory.  He  did  not  know  the  German  provinces, 
and  thought  that  Bismarck  had  once  been  war  minister. 
There  was  a  tremor,  hypalgesia  of  the  left  leg  and  analgesia 
of  the  left  arm  and  left  shoulder. 

It  was  found  that  he  came  from  a  strongly  tainted  family, 
with  two  insane  sisters  and  three  insane  cousins.  He  had 
been  a  good  soldier  during  his  service,  but  had  accused  his 
father  of  alcoholism  baselessly.  He  had  always  been  difficult 
to  manage  when  drunk  and  had  been  convicted  nine  times: 
five  for  dangerous  assault  and  battery.  He  drank  up  to  i| 
litres  of  whiskey  a  day  if  he  got  time,  and  also  took  ether. 
For  some  ten  years  he  had  been  amnestic  for  what  he  did 
while  drunk;  nor,  according  to  his  wife,  had  he  been  able 
recently  to  stand  so  much  alcohol.  He  said  that  he  had  had 
a  fall  from  a  wagon  in  191 1  or  '12,  after  which  he  had  been 
unconscious. 


130  PHARMACOPSYCHOSES 


Antebellum,  run  over  by  an  automobile;  intoler- 
ance of  alcohol;  episodes  of  amnesia  after  moder- 
ate alcohol. 


Case  97.     (Kastan,  January,  1916.) 

A  German  soldier  was  advanced  in  rank  February  26, 
1 91 5,  and  in  honor  thereof  drank  six  or  seven  glasses  of  beer. 
On  his  way  home,  he  met  a  captain  and  failed  to  salute  him. 
When  called  to  account,  he  said  he  could  not  see,  and  made 
remarks  about  regrettable  behavior.  He  refused  to  go  along 
with  the  officer.  Afterwards  he  remembered  that  he  had 
been  stopped  by  an  officer  but  had  forgotten  subsequent 
happenings. 

March  24,  he  was  riding  in  an  electric  car  with  a  lieutenant. 
He  said  to  the  lieutenant  who  had  unbuckled  his  sabre,  "It 
is  a  piece  of  insolence  and  improper  to  unbuckle  the  sabre." 
He  repeated  the  phrase  on  questioning.  He  was  then  asked 
to  give  his  name,  and  replied,  "  I  know  my  name  but  what  is 
your  name,  Mr.  Lieutenant?  "  He  looked  drunk  at  the  time 
but  afterwards  remembered  nothing. 

Physically  he  was  tremulous  and  showed  blepharospasm. 
His  face  grew  red  on  bending  over. 

This  man  had  been  run  over  by  an  automobile  in  1910, 
after  which  he  had  become  excitable,  slow-thinking  and 
forgetful.  The  spinous  processes  were  painful  on  pressure, 
as  was  also  the  hip  joint.  The  history  showed  that  he  had 
been  convicted  six  times  of  various  crimes,  such  as  disturbing 
the  peace,  embezzlement,  and  the  like.  Since  this  accident 
he  had  not  been  able  to  work  effectively.  He  had  gone  into 
the  army  in  a  spirit  of  enthusiasm. 


PHARMACOPSYCHOSES  I3I 

Adventure  with  a  stranger  in  Paris. 


Case  98.     (Briand  and  Haury,  1916.) 

A  soldier  had  seven  days'  leave  in  Paris,  beginning  Decem- 
ber 27,  1915,  and  the  first  day  drank  a  good  deal  of  wine  with 
another  man  on  leave.  They  met,  in  some  place  that  the 
patient  had  forgotten,  a  well-dressed  man  whom  they  did  not 
know,  and  all  three  fell  to  drinking.  The  stranger  told  them 
he  knew  a  trick  to  prolong  the  leave  to  3  or  4  weeks.  "All  I 
have  got  to  do  is  to  prick  you,  and  it  will  cost  only  100  sous." 
The  operation  was  done  at  the  cafe  after  payment  in  advance. 
The  operation  was  a  puncture  with  a  needle  between  the 
middle  and  ring  fingers  of  the  left  hand.  Next  day  there  was 
a  phlegmon  of  the  dorsal  surface  of  the  hand,  and  he  was  put 
into  hospital  saying  that  he  had  gotten  a  barbed  wire  prick 
in  the  trenches.  The  surgeon  who  opened  the  phlegmon  was 
surprised  at  its  gummy  appearance,  gangrenous  odor,  and 
greenish  tint.     In  point  of  fact,  petrol  had  been  injected. 


Morphinism:  Tetanus. 


Case  99.     (Briand,  1914.) 

Mdm.  L.  was  a  morphinist.  After  the  outbreak  of  the 
war,  she  went  to  a  general  hospital  to  recover  from  mor- 
phinism, but  was  too  excited  to  be  kept  there.  Accordingly, 
she  had  to  be  sent  to  Sainte-Anne,  but  upon  arrival  she 
developed  distinct  signs  of  tetanus. 

It  seems  that  Mdm.  L.  was  the  widow  of  a  Colonial  who 
had  given  her  the  first  injections  ten  years  before,  for  dysen- 
tery.   She  tried  several  times  to  stop.    Daily  dose  1.5  grams. 

She  was  in  a  cachectic  state,  and  according  to  her  mother, 
took  no  care  of  her  syringe,  trailing  it  about  everywhere. 
Her  thighs,  arms,  and  anterior  aspect  of  the  body  were  covered 
with  scars.  There  were  small  phlegmons  in  places.  Did  she 
inoculate  herself  with  bacillus  tetani  from  an  infected  needle? 
In  any  case,  she  died  of  tetanus. 


132  PHARMACOPSYCHOSES 

Medicolegal  question  concerning  a  morphinist. 


Case  100.     (Briand,  1914.) 

A  man  worked  in  Paris  on  the  'Change,  where  there  are  a 
number  of  syringe  victims.  He  had  been  brought  up  in  Paris 
but  was  not  a  Frenchman.  Enthused  by  his  friends  and  the 
prey  of  deep  emotion,  he  enUsted.  He  was  of  an  introspective 
nature  and  himself  wondered  whether  the  morphine  did  not 
have  something  to  do  with  his  enlisting.  He  said,  "I  had 
been  unnerved  for  a  number  of  days  by  readipg  the  papers, 
and  after  a  number  of  heavy  injections,  I  went  to  a  recruiting 
station  and  signed  on."  In  his  regiment,  he  continued  the 
injections,  but  shortly  found  that  he  would  be  unable  to 
replenish  his  diminishing  stock  of  drug.  He  explained  his 
unhappy  fate  to  the  corps  physician,  and  was  sent  to  Val-de- 
Grace.  He  asked  to  be  retired,  alleging  that  he  was  under 
the  influence  of  a  poison  when  he  went  to  the  recruiting  office 
and  had  therefore  committed  an  illegal  act. 


Social  effects  of  the  war  on  two  drug  addicts. 


Cases  loi  and  102.     (Briand,  1914.) 

Fernand  and  Emilienne  were  two  recidivists  in  morphinism. 
Although  neither  was  over  22  years  of  age,  both  had  been 
several  times  convicted  of  shop-lifting.  They  stole  only  if 
they  had  no  money  for  morphine.  Prostitution  served  to 
care  for  Emilienne,  while  Fernand  was  at  times  a  cocaine 
seller,  and  at  times  made  money  in  devious  ways  at  Mont- 
martre.  Emilienne's  patronage  scattered  with  the  war,  and 
it  was  the  same  with  Fernand's.  Accordingly,  there  was  no 
money  for  either  morphine  or  cocaine.  Moreover,  the  shops 
being  not  crowded  were  easier  to  watch.  As  Emilienne  did 
not  care  to  be  arrested  and  sent  off  as  an  undesirable,  she 
presented  herself  at  the  hospital  for  the  insane  at  Sainte- 
Anne.     Fernand  shortly  joined  her  there. 


V.   ENCEPHALOPSYCHOSES 
(THE   FOCAL   BRAIN   DISEASE  GROUP.) 


Left-sided  hemiplegia  and  aphasia :  Contrecoup  and 
local  lesions. 


Case  103.     (Lhermitte,  June,  1916.) 

A  soldier  of  23  was  wounded  in  the  left  parietal  region  and 
showed  a  Ze//-sided  hemiplegia  with  aphasia.  The  speech 
difficulty,  although  very  marked,  retrograded  almost  com- 
pletely, but  the  hemiplegia  remained  severe.  This  hemi- 
plegia was  a  spastic  one,  of  a  classical  nature,  with  Babinski 
sign  and  exaggeration  of  tendon  reflexes.  Lhermitte  thinks 
that  the  left  hemisphere  was  directly  affected  by  the  con- 
tusion, as  in  point  of  fact  there  was  an  actual  loss  of  bony 
tissue,  but  that  it  would  not  be  necessary  to  suppose  the 
ipsilateral  hemiplegia  was  due  to  an  absence  of  pyramidal 
decussation.  The  transient  aphasia  was  probably  due  to 
direct  affection  of  the  tissues  on  the  left  side  of  the  brain ;  the 
permanent  hemiplegia  was  doubtless  due  to  a  lesion  of  the 
opposite  hemisphere  produced  by  contrecoup.  It  appears 
that  sometimes  a  surgeon  may  be  led  to  superfluous  surgical 
intervention  in  a  case  of  such  paradoxical  hemiplegia,  since 
the  surgeon  may  believe  that  a  bullet  or  shell  fragment  has 
traversed  the  brain  substance  to  the  opposite  side  of  the  skull, 
when  as  a  matter  of  fact  the  brain  parts  have  been  injured 
merely  by  contrecoup. 

Re  such  amnesia,  it  is  of  note  that  many  head  cases,  even 
if  they  do  not  show  amnesia,  show  a  conspicuous  euphoria 
and  lack  of  understanding  of  the  seriousness  of  the  Injury 
in  question  and  of  the  necessary  treatment.  According  to 
E.  Meyer,  there  are  constantly  to  be  found  in  head  cases 
disturbances  of  perception  and  lack  of  coordination  (espe- 
cially for  time),  perseveration,  difficulty  in  thinking  and 
calculating. 

133 


134  ENCEPHALOPSYCHOSES 


COMMOTIO   CEREBRI 

I.   Senses:    Asymmetrical  hyp-  or  anesthesia  (with  hyperalgesia  and 
osseous  hyperesthesia). 

II.    Motility:    Disorder,    muscular  or   reflex.     General   or  unilateral 
hyperexcitability. 

III.  Vasomotor  Control:  Dermatographia.     Cardiac,  splanchnic  dis- 

order; also.  Headaches,  Vertigo. 

IV.  Emotions:   Disorder. 

V.    Intake  of  Ideas:   Disorder.     Persistent  lacunae  of  memory. 

VI.    Intelligence:  Disorder  of  recollective  memory.     Speech-disorder, 
Intellectual  inertia.     Overimagination  (hallucinations,  tremors). 

Mairet,  Pieron,  Bouzansky. 


Chart  5 


ENCEPHALOPSYCHOSES  1 35 

Gunshot  wound  of  head;  alcoholism:  Amnesia. 


Case  104.     (Kastan,  January,  1916.) 

A  German  soldier  had  a  bullet  pass  through  his  right  eye 
and  lower  jaw,  leaving  a  fistulous  opening  from  the  mouth. 
He  said  that  he  was  completely  bUnd,  but  ophthalmological 
examination  cast  doubt  upon  the  blindness.  There  had  been 
immediately  after  the  injury  a  number  of  severe  attacks  of 
dizziness,  which  lasted  several  hours;  and  another  attack 
developed  after  he  had  come  back  from  hospital,  to  which  he 
had  gone  by  reason  of  his  pains. 

He  was  to  be  arrested  on  account  of  a  disciplinary  crime 
and  had  ostensibly  gone  to  his  mother's  house,  there  to  await 
arrest.  The  non-commissioned  officer  found  him  in  a  saloon. 
As  soon  as  the  phrase,  "  You  are  my  prisoner !  "  was  said,  the 
soldier  lost  track  of  his  surroundings.  He  had  drunk  a  few 
glasses  of  beer  but  did  not  himself  think  he  was  drunk  at  the 
time.  He  was  insulting  and  violent  when  asked  to  proceed 
with  the  officer,  and  a  policeman  was  called  in  to  take  charge. 
He  then  lay  down  in  the  street  and  had  to  be  put  upon  a 
wagon,  still  firing  abusive  phrases  at  his  captors. 

Upon  examination,  aside  from  the  effects  of  the  gunshot, 
excessive  knee-jerks  and  tremors  of  the  body  were  found. 
The  eyebrows  met  but  there  was  no  other  sign  of  bodily 
stigmata.  There  seems  to  have  been  no  hereditary  disease, 
or  any  history  of  severe  alcoholism,  though  the  man  had  been 
convicted  previously  of  violence  and  theft.  The  amnesia  is 
to  be  ascribed  to  effects  of  the  head  injury. 


136  ENCEPHALOPSYCHOSES 


Bullet  in  brain :  Crises ;  cortical  blindness ;  vertigo ; 
hallucinations. 


Case  105.     (Lereboullet  and  Mouzon,  July,  1917.) 

An  invalided  soldier,  40,  was  sent  to  be  obser\^ed,  Oct.  23, 
1 91 6,  because  he  wanted  his  pension  renewed.  He  had  been 
retired  a  year  before  for  diminution  of  binocular  vision  with 
impaired  perspective  of  objects  in  the  right  half  of  the  visual 
field.     He  had  now  become  completely  blind. 

He  had  been  wounded,  March  12,  1915,  in  the  Argonne, 
without  losing  consciousness.  He  was  wounded  at  ten 
o'clock  at  night  and  waited  until  the  next  day  to  walk  to  the 
ambulance  and  was  at  this  time  able  to  see  perfectly.  Arriv- 
ing at  the  ambulance  he  lost  consciousness.  He  was  tre- 
phined but  remembers  nothing  about  the  trephining. 

His  memory  grew  better  from  his  arrival  at  a  hospital  in 
the  rear  in  April.  An  attempt  was  made  to  remove  the  bullet 
in  May,  191 5.  Though  the  surgeon's  finger  was  pushed  as 
far  as  the  tentorium  the  patient  did  not  lose  consciousness  or 
sight,  but  on  leaving  the  operating  room  he  fainted  and,  after 
a  few  days  of  restlessness  and  delirium,  he  became  completely 
blind.  There  was  a  cerebral  hernia  difficult  to  reduce. 
Vision  became  a  little  better  and  light  and  persons  could  be 
distinguished  at  the  time  when  he  was  retired.  A  month 
after  the  operation  there  was  a  convulsive  crisis  beginning  in 
the  left  arm,  affecting  the  legs  and  ending  in  unconsciousness. 
Several  similar  crises  occurred  in  August,  sometimes  with  and 
sometimes  without  loss  of  consciousness.  Later  these  crises 
began  to  be  limited  to  the  left  side  and  then  to  be  ushered  in 
by  visual  hallucinations.  At  home  he  was  unable  to  care  for, 
clothe  or  feed  himself.  The  crises  became  more  frequent. 
The  visual  hallucinations  began  to  dominate. 

This  situation  lasted  to  February,  191 6,  when  the  blind- 
ness which  had  been  increasing  since  the  onset  of  the  hallu- 
cinations became  complete.  The  crises  now  became  less 
frequent  and  intense.  Headaches  not  severe  were  exagger- 
ated after  seizures.     The  patient  acted  like  a  totally  blind 


ENCEPHALOPSYCHOSES  1 37 

person  and  said  that  he  had  before  him  a  uniform  and  con- 
stant gray  without  any  light  or  dark  spots  or  any  color. 
Upon  this  background  bizarre  pictures,  caricatures,  dis- 
guised persons,  animals  or  nameless  things  appeared  colorless 
without  relief,  in  silhouette,  but  highly  suggestive  of  reality 
to  such  a  degree  that  at  first,  according  to  the  patient,  he  had 
made  gestures  to  reach,  or  push  aside  these  pictures.  The 
crises  were  Jacksonian. 

Pallor,  perspiration,  shivering,  Irresponsiveness,  clonic 
spasms  of  left  arm  followed.  The  patient  always  had  a 
premonition  permitting  him  to  get  into  bed  if  he  was  sitting, 
for  example,  in  his  chair.  Sometimes  there  was  a  dizzy 
sensation  as  if  the  body  were  being  rotated  to  the  left.  This 
sensation  did  not  occur  at  the  beginning  of  the  seizure  and 
the  patient  fought  against  it,  turning  to  the  right.  Some- 
times he  felt  as  if  he  were  sliding  at  great  speed  down  an 
inclined  plane.  Headaches  and  sleepiness  followed,  but  there 
was  never  any  complete  loss  of  consciousness  of  memory. 

The  eye  grounds  proved  normal  and  all  the  photomotor 
reflexes  were  normal,  though  there  was  no  pupil  reflex  to  pain. 
The  patient  could  write  readily  to  dictation  printed  letters. 
It  would  seem  that  these  printed  letters  mean  that  he  had 
visual  memories,  as  he  traced  the  characters  as  If  from  a 
design.  Speech  was  monotonous  with  some  stuttering;  but 
his  speech  had  always  been  of  this  sort  according  to  informa- 
tion. He  walked  with  difficulty,  not  merely  on  account  of 
his  visual  but  on  account  of  his  equilibration  disorders. 
Outside  of  his  seizures  he  always  turned  to  the  right  and  if 
left  to  himself  standing  he  turned  to  the  right.  If  asked  to 
walk  straight  ahead,  he  always  turned  to  the  right.  Silent 
and  uncommunicative,  he  was  amiable  and  sometimes  even 
gay.  He  often  had  troublous  dreams,  sometimes  seeing  his 
relatives.  He  said  he  could  bring  up  in  his  mind  the  faces 
of  his  relatives  and  even  the  appearance  of  the  Salpetriere. 
Reflexes  and  sensations  were  normal.  There  was  a  traumatic 
rupture  of  the  tympanum.  Lumbar  puncture  showed  a  slight 
excess  of  albumin  and  1.8  lymphocytes  to  the  cubic  milli- 
meter. The  Mauser  bullet  was  found  by  X-ray  in  the  left 
calcarine  region  with  its  base  touching  the  median  line,  and 


138  ENCEPHALOPSYCHOSES 

applied  to  the  inner  table  of  the  skull  about  a  centimeter 
above  the  internal  occipital  protuberance  pointing  forward, 
outward,  and  upward.  He  was  treated  on  a  salt  free  diet 
with  bromides.  The  seizures  grew  fewer  and  at  the  time  of 
report  two  months  had  elapsed  with  nothing  but  a  slight 
vertigo  cind  frequent  nightmares.  Intellectually  also  the  pa- 
tient had  improved. 

The  case  is  one  of  cortical  blindness.  The  seizures  are 
explained  by  the  vicinity  of  the  right  Rolandic  region  to  the 
lesion.  The  rotatory  vertigo  is  to  be  explained  by  the  con- 
tact of  the  Mauser  bullet  with  the  tentorium  and  vermis  of 
the  cerebellum,  which  may  also  explain  the  difficulties  in 
orientation  that  occurred  between  the  crises.  The  visual 
hallucinations  are  doubtless  due  to  lesion  of  the  calcarine 
region. 


ENCEPHALOPSYCHOSES  I39 

Tunisian  theopath  with  mystical  hallucinations ;  gun- 
shot wound  of  occiput  (bullet  extracted) :  After 
the  tratima,  Lilliputian  hallucinations  and  micro- 
megalopsia. 


Case  106.     (Laignel-Lavastine  and  Courbon,  19 17.) 

A.  ben  S.  was  sent  to  Villejuif  with  the  diagnosis:  "depres- 
sion, feeling  of  impotence,  discouragement,"  having  been 
found  on  the  pubHc  street.  He  was  indifferent,  almost  com- 
pletely mute,  and  was  at  first  considered  not  to  understand 
French.  In  a  fortnight,  however,  he  was  talking  freely  and 
was  then  found  to  be  afflicted  with  hallucinations,  melancho- 
lia, and  delusions,  apparently  following  trauma  to  the  skull. 

A.  ben  S.  might  have  been  about  thirty  years  old,  and  was 
of  a  rich  family,  indigenous  in  Tunis,  well  educated  in  the 
Koran  and  Arabic  literature. 

Upon  examination,  this  Tunisian  gunner  showed  contrac- 
tion of  visual  fields,  poor  color  vision,  and  general  hypalgesla. 
During  examination,  the  man  seized  the  needle  and  plunged 
it  deeply  under  his  skin,  exclaiming  that  a  prophet  felt  nothing 
and  that  he  could  be  cut  into  bits  without  feeling  pain. 

It  seems  that  he  had  had  divine  visions  from  early  child- 
hood. In  his  youth  he  had  once  gone  to  a  mountain  near  his 
home  and  talked  with  Mohammed  and  Allah.  Of  course, 
Allah  did  not  appear  In  human  form,  but  he  appeared  like 
a  ball  or  a  wheel  of  fire,  slowly  turning.  Mohammed  was  a 
tall  man,  with  a  long  white  beard,  his  eyes  darting  rays  of 
fire,  and  his  forehead  bearing  a  gleaming  bright  body.  Allah 
was  heard  talking  to  Mohammed.  Orders  were  given  con- 
cerning the  sun  and  stars.  Subterranean  treasures  were 
displayed,  as  well  as  Paradise  full  of  yellow,  blue,  and  green 
houris,  transparent,  such  that,  when  food  was  taken,  it  could 
be  seen  going  down  their  throats.  Hell  too  was  visible,  and 
the  devil  very  tall  and  black,  an  eye  behind  and  another  on 
top.  There  were  also  many  genii  —  little  men  who  climbed 
over  the  Tunisian's  body.  Sometimes  in  dreams,  Allah 
carried  him  to  all  countries  of  the  earth.     It  was  hard  to  tell 


140  ENCEPHALOPSYCHOSES 

whether  these  effects  were  hallucinations  or  vivid  imaginings. 
The  Tunisian  had  been  wounded  after  several  months  of 
service  by  two  bullets  in  one  day :  the  one  causing  an  insignifi- 
cant lip- wound ;  the  other  entering  the  skull  behind.  After 
several  months  the  bullet  had  been  extracted  by  trephining. 
His  further  history  was  obscured  by  the  fact  that  he  wove 
delusional  elements  into  his  story.  He  said,  for  example, 
that  he  had  been  court-martialed,  though  there  was  no 
evidence  that  this  was  a  fact.  It  is  probable  that  after  his 
wound  the  patient  in  a  delirium  felt  that  he  was  going  to  be 
shot.  The  visual  hallucinations  were  very  interesting,  being 
Lilliputian.  He  would  see  three  or  four  hundred  Tunisian 
gunners  walking  along,  knee-high  or  taller.  Sometimes  they 
all  would  stop  and  aim  at  him.  He  also  showed  micromegal- 
opsia,  real  objects  changing  their  height  under  his  eyes. 
Both  the  Lilliputian  hallucinations  and  the  micromegalopsia 
dated  from  the  trauma  to  the  skull.  There  was  no  change 
whatever  In  the  mystical  delusions  concerning  Allah  and 
Mohammed.     These  he  had  before  the  trauma. 


ENCEPHALOPSYCHOSES  I4I 


Meningococcus  meningitis  with  apparent  recovery : 
Dementing  psychosis. 


Case  107.     (Maixandeau,  1915.) 

A  soldier  in  the  Heavy  Artillery,  42,  developed  occipital 
headaches  and  Kemig's  sign,  December  27,  1915. 

December  31,  at  the  Hotel-Dieu,  he  showed  myosis,  slight 
photophobia,  menlngitic  tache,  temperature  39.6,  pulse  84, 
heart  sounds  dull.     Lumbar  puncture:  hemorrhagic  fluid. 

January  i,  the  headache  was  Intense,  neck  stiffness  in- 
creased, Kemig's  sign  less  marked;  morning  and  afternoon 
temperature  39.2.  Lumbar  puncture  yielded  hypertensive 
cloudy  fluid  and  30  cubic  centimeters  of  serum  were  ad- 
ministered. 

This  dose  was  repeated  January  2  and  January  3,  on  which 
date  there  was  no  headache. 

January  4,  Kernlg's  sign  and  neck  stiffness  were  dimin- 
ished; fine  rales  at  the  bases  without  dulness.  30  cubic  cen- 
timeters of  electragol  were  injected  Intravenously. 

January  5,  Kernig  and  neck  stiffness  slight.  Meningltic 
tache;  exaggerated  knee-jerks;  unequal  pupils;  temp.  36.6 
morning,  39.4  afternoon;  respiration  36 ;  pulse  120;  norMes; 
splenic  enlargement. 

6,  no  headache  or  photophobia;  constipation;  fine  r^les, 
right  base;  spartein;  meningococci  found  In  hypertensive 
spinal  fluid.     30  cc.  serum. 

7,  more  rales;  exaggerated  heart  sounds;  intestinal  worms 
in  stools. 

8,  temperature  fell  to  37 ;  pulse  to  90. 

9,  patient  worse;  involuntary  stools;  Kernlg's  sign;  stiff 
neck;  fever.     30  cc.  serum  injected. 

10,  20  cc.  Injected. 

11,  delirious  all  night;  tetaniform  stiffness  of  neck;  more 
rales. 

12,  delirious.  Incoherent  words,  Cheyne-Stokes  breathing. 

13,  less  stiffness,  Kernig  almost  absent;  pupils  normal; 
Romberg  sign  slightly  developed;   pulse  120. 


142  ENCEPHALOPSYCHOSES 

14,  a  few  rales  at  right  base. 

15,  pains  in  elbows,  knees  and  hands  with  joint  swelling; 
moist  rales;  temp.  38.4;  pulse  140.     Digitalon. 

16  and  17,  serum  erythema  of  thorax;  edema  of  left  knee; 
pulse  150;   spartein  16. 

17,  ice  pack  over  heart. 

18,  edema  of  knee  diminished;  no  headache,  delirium  or 
pupillary  sign. 

19,  improvement.     Temperature  normal  thereafter. 

20  and  21,  fine  rales.     Then  all  symptoms  disappeared. 

Recovery  was  predicted,  but  on  January  28  it  was  observed 
that  the  patient  was  untidy,  made  mistakes  in  dressing, 
such  as  trying  to  put  his  legs  into  the  armholes  of  his  shirt, 
and  denied  the  most  evident  facts:  His  kepi  on  his  head,  he 
said  it  was  not.  Face  drawn;  skin  yellow.  Appearance  of 
asthenia.  Deep  depression  and  hebetude.  At  this  time 
the  knee-jerks  were  exaggerated,  pupils  unequal,  vermicular 
tremor  of  tongue;  the  patient  walked  on  a  broad  base  with 
tremulous  legs  suggesting  contracture  and  weakness. 

February  8,  in  a  similar  state  the  patient  wandered  about 
his  room,  moving  his  bed  and  chairs  about,  answering  ques- 
tions with  an  absent  air.  He  had  now  been  taught  to  be  less 
untidy. 

March  5,  stiff  neck  and  Kemig's  sign  were  distinct.  He 
made  believe  he  was  on  his  farm.  Ecchymosis  of  right  upper 
eyelid:  he  had  fallen  (his  sheep  had  pushed  him  over!).  The 
improbability  of  this  idea  did  not  persuade  him  to  think  it 
had  not  happened.     He  walked  after  the  manner  of  a  tabetic. 

In  April  he  became  bedridden,  unable  to  walk,  with  marked 
stiffness  and  Kemig's  sign.  He  had  at  this  time  periods  of 
excitement  in  which  he  would  tear  the  bedclothes.  He  was 
invalided  as  demented. 


ENCEPHALOPSYCHOSES  I43 

Meningococcus  meningitis. 


Case  108.     (EscHBACH  and  Lacaze,  November,  191 5.) 

During  his  eleven  months  captivity  at  Grafenwohr,  Esch- 
bach  and  Lacaze  had  the  opportunity  of  observing  the  case  of 
a  soldier,  24,  who  sustained  a  shell-wound  in  the  left  lung  and 
was  made  prisoner  August  20,  1914,  at  Chateau  Salins.  He 
got  well  of  his  wound,  but  February  16,  19 15,  began  to  cry 
out  and  was  restless  in  the  night.  He  was  found  on  the  straw 
muttering  words  among  which  only  the  word,  "Head,  head," 
could  be  distinguished.  He  was  irresponsive,  possibly  deaf. 
Suddenly  he  had  a  convulsive  crisis  and  whenever  touched 
he  would  have  jactitations  and  cry  out.  Otherwise,  he  was 
calm  and  stuporous.  The  pupils  were  widely  dilated.  In 
short,  he  showed  a  mental  confusion  associated  with  paroxys- 
mal excitement  due  to  cerebral  and  cutaneous  hyperesthesia. 
The  first  symptoms  had  occurred  the  morning  before,  when 
he  leaned  his  head  against  a  wall  and  complained. 

Lumbar  puncture  yielded  intra-  and  extracellular  meningo- 
cocci. The  patient  was  isolated.  In  the  afternoon  he  be- 
came less  agitated,  kept  his  eyes  closed,  mumbled,  repeated 
gestures,  would  spit  in  his  hands,  rub  his  hands  together,  rub 
his  neck,  shoulders  and  body,  or  else  he  would  pass  his  hands 
over  his  forehead  and  through  his  hair.  Occasionally  he 
would  seize  the  straw  and  draw  it  to  him  with  all  his  strength. 
Once  when  asked,  "What  is  your  name?"  he  said,  "Not 
true.  Not  true."  Hallucinations  appeared  to  have  been 
added  to  the  situation.  The  neck  was  a  little  stiff  to  forced 
flexion.  Temperature  37.8.  Lumbar  puncture  under  chloro- 
form anesthesia;  antimeningococcus  serum  was  injected. 
Next  day  quieter ;  able  to  get  up  and  walk.  Slept,  mumbled 
less,  was  able  to  answer  simple  questions,  desired  to  urinate 
and  finally  succeeded. 

February  19,  no  mental  disorder.  Headache  and  lassi- 
tude. Neck  stiff,  Kemig's  sign  marked.  Lumbar  puncture 
yielded  a  fluid  now  puriform;  antimeningococcus  serum 
injected.  February  20,  lifting  the  head  produced  opistho- 
tonos.    Labial  herpes.     The  fluid  yielded,   besides  menin- 


144  ENCEPHALOPSYCHOSES 

gococci,  also  endothelial  cells.  Serum  injected.  February 
21,  fibrin  in  fluid;  serum  injected.  February  22,  no  head 
symptoms.  Herpes  more  intense,  involving  also  arms. 
Tongue  coated.  Temperature  37.5,  evening  38.3.  Febru- 
ary 23,  meningococci  and  lymphocytes  in  fluid.  February 
24,  left  knee  swollen.  Serum  injected ;  puncture  fluid  showed 
meningococci  and  polynucleosis.  Fluid  from  knee  showed 
polynuclear  cells  without  organisms.  February  25,  patient 
reached  evening  temperature  of  39.5;  serum  injected.  A 
few  meningococci,  altered  polynuclear  leucocytes.  February 
26,  patient  rigid,  tongue  coated,  serum  injection.  Rare 
meningococci,  degenerated  polynuclear  leucocytes.  Febru- 
ary 27,  rigidity  decreased,  evening  temperature  37.7.  Febru- 
ary 28,  Kemig's  sign  absent.  Herpes  dry.  Serum  injec- 
tion. Fluid  clear;  lymphocytes  and  polynuclear  cells;  no 
meningococci.  March  6,  painful  inguinal  gland  on  the  left 
side.  March  7,  epididymitis  left  (mumps  two  years  before, 
with  headache  two  weeks  and  double  orchitis).  March  9, 
serum  eruption.  March  17,  epididymitis  practically  absent. 
Lymph  node  painful.  Later  data  impossible  to  get,  except 
that  there  was  apparently  an  arthritis  of  the  hip  and  a  sacral 
decubitus  with  eventual  recovery. 


ENCEPHALOPSYCHOSES  1 45 


Shell-explosion:    Meningitic    syndrome,    fourteen 
months. 


Case  109.  (PiTREs  AND  Marchand,  November,  1916.) 
A  soldier  sustained  shell-shock  at  the  distance  of  a  meter 
at  Saint-Hilaire,  September  26,  1915.  He  lost  consciousness 
and  blood  flowed  from  his  ears.  He  arrived,  September  28, 
at  the  neurological  center  in  Bordeaux  in  a  semistupor, 
knowing  that  he  had  been  shocked  and  had  lost  consciousness. 
He  groaned,  cried  out,  and  kept  stroking  his  head  with  his 
right  hand;  lay  on  the  right  side ;  showed  Kernig's  sign  right, 
ptosis,  and  stiff  neck.  Headache  was  increased  on  moving 
and  noises.  Patient  constantly  asked  for  food^  but  refused 
to  drink.  Lumbar  puncture  yielded  a  yellowish  fluid,  due 
to  laked  blood.  October  3,  headache,  ptosis,  left  internal 
strabismus,  temperature  38.5.  October  4,  lumbar  puncture, 
slightly  blood-tinted  fluid.  October  5,  improvement;  gap 
in  memory  for  period  since  shock.  No  strabismus,  ptosis 
diminished,  temperature  normal,  improvement  continued. 
Kernig's  sign  and  headache  persisted.  He  lay  doubled  up 
on  the  right  side,  eyes  closed,  right  hand  on  pillow.  Defense 
movements  on  touching  the  neck  or  occipital  region.  The 
condition  of  semistupor  often  passed  off  in  the  afternoon, 
when  he  could  talk,  write  or  play  cards.  He  had  always 
smoked,  even  at  the  beginning  of  his  disease.  Lumbar 
puncture  yielded  a  normal  fluid  December  12,  191 5.  He  was 
sent  February  23,  19 16,  to  a  hospital  in  the  country,  but 
came  back  May  9. 

It  seems  that  several  days  after  transfer  he  had  had  an 
attack  of  delirium  in  the  night,  having  lost  consciousness,  and 
tried  continually  to  get  up  out  of  bed,  saying  that  he  wanted 
to  go  to  Verdun  to  fight.  This  spell  lasted  several  hours  and 
on  the  days  following  came  mutism,  refusal  of  food,  and  a 
state  of  stupor.  Nutritive  enemata  were  given.  As  he  grew 
better  he  sometimes  ate  a  great  deal,  sometimes  nothing, 
even  wanted  poison  from  his  family,  and  wrote  to  a  comrade 
that  he  wanted  to  commit  suicide. 


146  ENCEPHALOPSYCHOSES 

May  9,  he  was  clearer,  told  of  seeing  the  shell,  which  he 
said  he  had  not  heard,  nor  did  he  know  how  he  had  gotten  to 
a  hospital.  His  head  and  spine  had  hurt  him  ever  since  the 
shock.  He  had  had  difficulty  in  urination  for  two  days  after 
the  shock.  He  could  not  remember  the  delirious  attack  in 
the  country  hospital.  He  gave  various  data  about  his  life, 
but  not  fully.  He  refused  to  lie  on  the  left  side,  or  to  walk, 
because  of  pain.  He  could  lift  either  leg  from  the  bed,  but 
hardly  both.  There  was  an  irregular  coarse  tremor  of  the 
extremities.  The  right  hand  was  weaker  than  the  left; 
there  were  no  reflex  disorders ;  no  change  in  the  eye  grounds. 
There  was  a  patchy  analgesia.  May  26,  stupor  reappeared 
as  before,  with  semimutism.  June,  the  patient  presented 
the  appearance  of  a  dementia  praecox  in  stupor,  with  stere- 
otyped gestures  and  attitudes,  without  catatonia.  The 
patient  was  sent  to  a  hospital  for  the  insane  at  Cadillac. 
November  9,  1916,  he  returned  to  the  neurological  center,  as 
mental  and  cerebral  disorder  had  disappeared.  There  still 
persisted  a  difficulty  in  remembering  facts  since  the  shock  and 
there  was  still  a  functional  paresis  of  the  legs. 

We  here  deal  with  a  case  of  a  meningitic  syndrome  follow- 
ing shell-shock  and  lasting  fourteen  months. 


ENCEPHALOPSYCHOSES  1 47 


Brain  abscess  in  a  syphilitic:  Matutinal  loss  of 
knee-jerks. 


Case  no.     (Dumolard,  Rebierre,  Quellien,  1916.) 

An  unmarried  subaltern  officer,  30,  entered  an  army  neuro- 
psychiatric  center,  April  8,  1915,  looking  exhausted  and  bear- 
ing a  ticket  "nervous  asthenia,  evacuated  for  neurological 
examination."  He  said  he  had  had  scarlet  fever  at  ten; 
strongly  denied  syphilis,  of  which  he  presented  no  trace; 
had  not  been  excessively  alcoholic  and  had  had  no  nervous 
seizures.  Detailed  information  showed  that  he  had  been  a 
normal  child.  He  left  his  two  years'  military  service  with 
promotion  and  was  a  man  of  above  the  ordinary  intelligence. 

He  was  wounded  in  the  right  buttock  with  a  shrapnel  bullet 
about  the  end  of  September,  19 14.  He  went  back  to  his 
regiment  two  months  later  and  had  shared  in  a  number  of 
actions  up  to  the  time  of  his  evacuation.  He  said  he  had  been 
very  tired  for  several  weeks,  and  had  finally  been  sent  to  the 
physician.  There  were  pains  in  the  kidney  region  and  in  the 
head,  especially  on  the  right  side.  The  head  felt  empty. 
He  could  not  sleep,  but  did  not  dream.  Ideas  were  not 
distinct.  Memory  had  become  impaired.  He  could  not 
keep  his  accounts  right,  and  was  afraid  something  might  go 
wrong. 

There  was  no  pain  or -nervous  or  reflex  disorder  of  any  sort 
except  for  the  knee-jerks  and  Achilles  jerks  (see  below). 
A  special  examination  proved  complete  normality  of  eyes. 
There  was  a  slight  hesitation  in  words,  but  no  dysarthria. 
There  was  a  slight  tremor  of  the  tongue  and  fingers. 

As  to  the  tendon  reflexes,  April  9,  on  waking,  the  knee-jerks 
were  absent,  but  later  in  the  day  gradually  came  in  evidence 
again.  The  Achilles  jerks  were  also  absent  at  first,  but  could 
be  obtained  after  a  prolonged  examination  and  after  percus- 
sion of  the  calf.  In  the  afternoon,  after  exercise,  the  knee- 
jerks  and  Achilles  jerks  were  easily  demonstrable.  The  left 
Achilles  jerk  was  always  a  little  weaker  than  the  right. 
Massage  brought  these  jerks  out  to  virtual  normality.     April 


148  ENCEPHALOPSYCHOSES 

10  and  thereafter,  similar  findings;  percussion  of  the  mus- 
cular masses  of  the  thighs  and  calves  always  brought  out  the 
reflexes. 

Lumbar  puncture  yielded  a  clear  fluid  with  hyperalbumino- 
sis,  20  cells  per  c.mm.  (lymphocytes  and  mononuclear  cells  95 
per  cent)  and  a  positive  W.  R.  Iodide  of  mercury  treatment 
was  given  April  18. 

April  23,  the  patient  went  into  a  coma,  with  trismus,  stiff 
neck,  Kemig's  sign,  sluggish  pupils,  incontinence.  He  was 
transferred  to  a  special  hospital,  showed  on  lumbar  puncture, 
April  23,  85  per  cent  polynuclear  leucocytes,  and  died  April 
27.  The  autopsy  showed  a  yellowish,  quasidiffluent  softening 
of  the  size  of  a  small  egg  in  the  first  occipital  gyrus  on  the  right 
side.  The  authors  comment  on  the  fact  that  the  only  objec- 
tive sign  in  this  case  was  the  variable  tendon  reflexes  of  the 
lower  extremities,  "Tumque  cri  de  souffrance  des  centres 
nerveux." 


ENCEPHALOPSYCHOSES  I49 

Early  recovery  from  a  spinal  cord  lesion. 


Case  III.     (Mendelssohn,  January,  1916.) 

Mendelssohn  reports  a  soldier,  who  was  sent  to  a  Russian 
hospital,  April  12,  191 5,  with  a  diagnosis  of  chronic  appendi- 
citis. Operated  on  next  day,  the  patient  appeared  to  be 
passing  through  a  normal  convalescence,  when  ten  days  later, 
he  had  an  intense  headache  and  some  trouble  in  vision,  which 
disappeared  the  next  day,  only  to  be  followed,  two  days  later, 
by  the  patient's  complaint  that  he  could  no  longer  urinate  or 
rise  from  bed. 

In  fact,  Mendelssohn  found  a  complete  flaccid  paraplegia 
with  urinary  retention,  without  fever  or  pain.  Knee-jerks 
and  Achilles  jerks  were  absent,  and  there  was  a.  slight  exten- 
sion of  the  great  toe  on  plantar  stimulation.  There  was 
disorder  of  sensation,  with  heat  sensibility  abolished,  painful 
points  poorly  localized,  and  position  sense  poor.  Electric 
reactions  normal.  Pain  on  pressure  in  and  about  the  lumbar 
vertebral  region.  Cerebrospinal  fluid  showed  lymphocytosis 
and  an  excessive  albuminosis. 

This  paraplegia  lasted  six  weeks.  At  the  end  of  May,  the 
patient  began  to  be  able  to  move  his  toes  and  to  lift  his  heel. 
Improvement  was  gradual  and  progressive.  Early  in  June 
he  could  walk  if  supported.  The  weak  knee-jerk  then  began 
to  reappear  and  the  urinary  retention  gradually  disappeared. 

This  patient  was  not  hysterical,  although  a  bit  emotional. 
Perhaps,  according  to  Mendelssohn,  an  organic  lesion  was 
grafted  on  a  neurosis.  Perhaps  the  spinal  lesion  was  infec- 
tious. At  any  rate,  a  presumably  organic  paraplegia  had 
recovered  in  two  months  and  a  half. 


I50  ENCEPHALOPSYCHOSES 


Shell-explosion :  Meningeal  hemorrhage :  Pneumo- 
coccus  meningitis. 


Case  112.  (GuiLLAiN  and  Barre,  August,  191 7.) 
An  infantryman,  20,  came  to  the  Sixth  Army  Neurological 
Center,  October  13,  1916,  as  a  case  of  "choluria,  due  to  shell 
explosion;  epistaxis  needs  watching."  He  was  somnolent, 
had  waked  vomiting,  pulse  108.  Kernig's  sign,  defensive 
movements  of  the  legs  on  stimulation,  with  flexion  of  leg  on 
thigh  and  of  thigh  on  pelvis,  plantar  reflexes  flexor.  Punc- 
ture showed  typical  meningeal  hemorrhage.  Two  days  later, 
temperature  40,  pulse  70,  that  is  to  say,  a  bradycardia  in 
proportion  to  the  fever.  Vomiting,  pulse  persisted.  Next 
day  the  patient  was  moaning  and  semi-delirious  and  showed 
stiff  neck,  Kernig's  sign,  accentuation  of  vasomotor  disorder ,- 
plantar  response  flexor  with  leg  retracted,  thigh  flexion  both 
homolateral  and  contralateral.  The  spinal  fluid  upon  the 
next  day,  that  is,  four  days  after  his  arrival  at  the  clinic, 
showed  a  purulent  fluid  in  which  there  was  an  excess  of 
albumin,  no  sugar,  diplococci  extracellular  (proving  on  cul- 
ture to  be  pneumococci  and  able  to  kill  a  mouse  in  twenty- 
four  hours). 

As  a  rule  such  hemorrhages  remain  aseptic,  and  in  fact 
meningeal  hemorrhage  is  said  by  Guillain  and  Barre  to  have, 
as  a  rule,  a  favorable  prognosis.  The  above  described  case 
was  the  only  one  of  infected  meningeal  hemorrhage  that  had 
occurred  in  the  Sixth  Army  Neurological  Center. 


ENCEPHALOPSYCHOSES  I5I 


ANTEBELLUM  cortex  lesion:  right  hemiplegia; 
recovery.  Struck  by  shrapnel  on  right  shoulder : 
Athetosis. 


Case  113.     (Batten,  January,  1 91 6.) 

A  British  soldier,  aged  2'j,  showed  a  somewhat  remarkable 
phenomenon.  It  appears  that  at  five  years  of  age,  this  man 
had  had  poliomyelitis,  affecting  the  left  leg.  At  20  years  of 
age,  he  had  had  pneumonia,  and  this  had  been  followed  by  a 
paralysis  of  the  right  arm  and  leg  with  a  loss  of  speech.  The 
man  recovered  from  this  illness,  although  he  never  quite 
regained  full  control  of  the  right  hand.  It  is  evident  that 
this  lack  of  control  was  not  marked,  else  the  man  would  not 
have  been  enlisted,  and  it  is  Dr.  Batten's  opinion  that  at  all 
events  he  could  not  have  shown  pathological  movements  of 
the  right  hand  at  the  time  of  enlistment. 

However  this  may  be,  in  October,  1914,  the  soldier  was 
struck  on  the  right  shoulder  with  shrapnel.  Apparently  he 
was  not  wounded,  but  thereafter  he  was  not  able  to  use  the 
right  arm  well,  and  in  two  months'  time  he  had  become 
unable  to  manipulate  his  rifle.  On  January  13,  1915,  he  was 
sent  home.  The  remnants  of  the  old  poliomyelitis  of  the  left 
leg  were  shown  in  a  general  weakness  of  that  leg  as  compared 
with  the  right.  The  movements  of  the  right  hand  were  those 
seen  in  athetosis.  The  movements  were  independent  of  voli- 
tion. The  patient  had  difficulty  in  releasing  his  grasp.  He 
improved  rapidly  during  the  six  weeks  he  was  in  hospital, 
although  the  movements  of  the  right  hand  never  became 
entirely  normal. 

In  this  case,  according  to  Batten,  "the  stress  was  sufficient 
to  bring  into  prominence  the  symptoms  due  to  an  old  cerebral 
lesion." 


152  ENCEPHALOPSYCHOSES 


Hysterical  versus  thalamic  hemianesthesia. 


Case  114.     (Leri,  October,  1916.) 

A  soldier,  40,  had  been  suffering  for  a  number  of  months 
with  pains  in  the  left  side  of  the  trunk  and  feelings  of  weakness 
in  the  left  arm  and  leg.  In  the  summer  of  191 5  he  was  on 
leave  and  while  walking,  fell,  lay  down,  and  found  he  could 
hardly  move  his  left  arm  and  leg.  Two  or  three  weeks  later 
he  got  up,  walking  with  a  stick.  After  some  time  in  hospital, 
he  was  sent  back  to  the  trenches,  a  little  weak. 

He  had  shortly,  however,  to  be  examined  neurologically 
again.  He  could  hardly  raise  the  left  leg  and  his  passive 
resistance  was  poor  on  this  side.  The  left  side  was  almost 
completely  anesthetic  to  all  forms  of  stimulus,  although  an 
intense  faradic  current  yielded  a  feeling  like  that  of  a  fly. 
Nor  was  the  tactile  sensation  absolutely  nil,  as  it  could  be 
got  with  a  fiat  finger  on  the  upper  arm  and  thigh.  Cold  and 
heat  sensations  not  well  localized.  The  hemianesthesia  was 
sharply  limited  at  the  median  line  and  affected  the  buccal, 
lingual  and  nasal  mucosa.  Deep  sensibility  was  almost 
abolished  on  the  left  side.  Stereognostic  sense  was  lost  and 
the  sense  of  position  was  lost  absolutely  for  hand  and  foot. 

The  patient  said  that  he  heard  less  well  on  the  left  side. 
There  was  also  a  slight  contraction  of  the  left  visual  field. 
The  reflexes  were  lively,  but  equal  on  both  sides.  A  diag- 
nosis of  hysterical  hemianesthesia  was  apparently  called  for, 
but  psychoelectric  treatment  failed.  The  plantar  reflex  was, 
in  fact,  completely  absent  on  the  left  side,  as  well  as  the  cor- 
neal reflex.  The  faradic  current  failed  to  produce  as  marked 
a  dilatation  of  the  pupil  on  the  left  side  as  on  the  right.  The 
forehead  wrinkles  were  less  marked  on  the  left  side.  The 
mouth  deviated  slightly  to  the  right.  The  left  nasolabial 
fold  was  a  little  less  marked.  The  tongue  did  not  deviate, 
but  was  a  little  narrow  on  the  left  side.  The  palate  deviated 
a  little  to  the  left.  The  left  side  of  the  trunk  seemed  a  little 
less  developed  than  the  right,  and  the  scapula  stuck  a  littie 
less  closely  to  the  body  on  the  left  side,  when  the  arms  were 
raised.     The  left  buttock  was  a  little  narrower  than  the  right 


ENCEPHALOPSYCHOSES  153 

and  the  left  gluteal  fold  was  less  marked.  In  combined 
flexion  of  thigh  and  trunk  the  left  foot  readily  left  the  floor. 
There  was  a  left-sided  hypotonia  in  forced  flexion  of  the  fore- 
arm. There  were  no  tremors  of  the  limbs  in  repose,  except 
a  few  contractions  of  the  left  lower  extremity.  In  movement, 
however,  there  was  a  marked  tremor  and  in  coordination  the 
finger  to  nose  test  could  not  be  performed.  Speech  was  slow 
and  hesitant,  sometimes  stuttering.  Food  was  sometimes 
taken  into  the  air  passages.  Headaches  were  localized  on 
the  right  side.  They  had  begun  when  the  first  symptoms 
began.  There  was  mental  disorder,  with  gaps  in  memory. 
In  short,  the  case  is  probably  one  of  thalamic  disease,  though 
there  were  no  pains  except  a  few  in  the  left  side  of  the  trunk 
at  the  beginning  of  the  disease.  The  diagnosis  of  hysteria 
was  at  first  made  in  this  case,  but  the  rule  that  hysterical 
hemianesthesia  is  never  found  without  auto-  or  hetero-sug- 
gestion  caused  the  alteration  of  diagnosis  to  thalamic. 


154  ENCEPHALOPSYCHOSES 


Shell-explosion:     Syndrome    suggesting    multiple 
sclerosis. 


Case  115.     (PiTRES  AND  Marchand,  November,  1916.) 

A  soldier,  40,  carriage  painter,  underwent  shell-shock  at 
Voquois,  May  2,  191 5,  following  ten  hours'  bombardment. 
At  the  time  he  felt  tinglings.  The  bombardment  had  just 
ceased  when  he  fainted  suddenly  while  repairing  a  telegraph 
line.  There  was  no  loss  of  consciousness.  He  could  not 
move  his  arms  or  legs,  was  able  to  spit,  and  did  not  suffer  at 
all  except  for  the  tingling.  He  was  evacuated  to  the  interior, 
where  the  diagnosis  of  psychopathic  double  paraplegia,  Ker- 
nig's  sign,  zones  of  anesthesia  in  the  legs,  was  made.  He  was 
immediately  treated  with  gray  oil,  and  got  an  injection  of 
neosalvarsan,  and  iodides.  He  grew  slowly  better.  He 
could  lift  a  leg  from  the  bed,  but  then  both  legs  began  to 
tremble.  The  arms  had  recovered  their  movement,  before 
the  legs,  but  always  trembled  in  movement. 

November,  191 5,  he  was  able  to  get  up;  two  months  later, 
he  walked  alone. 

At  the  neurological  center,  which  he  entered  December  17, 
his  gaze  was  fixed  and  there  was  a  slight  exophthalmos.  The 
folds  of  the  face  were  smoothed  out.  The  nose  was  deep  set 
(as  a  result  of  a  fall  at  the  age  of  eight).  In  the  upright  posi- 
tion he  could  not  remain  still,  but  trembled  markedly  on  the 
left  side,  so  that  he  had  to  make  a  few  steps  to  keep  his  bal- 
ance. He  was  unable  to  stand  on  his  left  leg.  He  walked 
on  a  broad  base,  in  little  steps,  and  rather  unsteadily  on 
account  of  tremors  augmenting  upon  movement.  General 
muscular  weakness;  left  hand  slightly  weaker  than  right. 
He  could  not  lift  both  legs  more  than  20  cm.  from  the  bed 
and  in  the  process  they  both  trembled,  trembling  together. 
There  was  also  intention-tremor  of  the  arms,  a  little  less 
marked  than  that  of  the  legs,  of  an  irregular  rhythm.  The 
arms  trembled  as  a  whole.  In  a  state  of  rest  there  was  no 
tremor.  There  was  a  slight  muscular  stiffness  and  the  patient 
himself  felt  difficulty  in  relaxing.     Patellar  reflexes  absent, 


ENCEPHALOPSYCHOSES  1 55 

even  on  reinforcement;  Achilles  jerks  absent.  Speech  monot- 
onous and  tremulous,  but  not  scanning;  syllable  doubling 
observed  by  the  patient.  Manuscript  tremulous  and,  on 
account  of  tremors,  illegible.  Hypalgesia  of  legs,  more 
marked  distally.  Deep  sensibility  of  tendo  Achillis  and  patel- 
lar reflexes  lost.  Pain  on  compression  of  eyes  diminished. 
Formication  in  arms.  W.  R.  of  blood  negative.  Slow  im- 
provement followed  and  the  patient  left  the  neurological 
service  May  4,  1916,  able  to  walk  more  easily  and  without 
tremor.     The  knee-jerks  and  Achilles  jerks  were  still  absent. 

We  here  deal  with  a  syndrome  in  part  that  of  a  multiple 
sclerosis,  that  is,  the  intention-tremor,  gait  disturbance, 
muscular  rigidity,  and  weakness. 

Re  multiple  sclerosis,  Lepine  remarks  that  there  are  nu- 
merous army  cases  of  pseudo  multiple  sclerosis  which  are 
actually  hysterical  or  hystero-traumatic  cases  of  hypertonus 
and  tremor.  The  true  cases  of  multiple  sclerosis,  according 
to  Lepine,  are  of  interest  inasmuch  as  they  are  usually  found 
in  officers.  These  men  have  apparently  at  first  but  a  slight 
motor  disorder,  quite  compatible  with  desk  work.  We  have 
usually  under-rated  the  cortical  element  in  multiple  sclerosis. 
Spells  of  confusion,  delusional  ideas,  sometimes  grandiose, 
start  up  without  warning  in  these  cases.  To  be  sure,  alcohol 
and  syphilis  sometimes  also  enter  these  cases  etiologically. 
Any  case  of  localized  tremor  ought  to  be  carefully  examined 
psychically,  and  such  cases  in  general  ought  not  to  be  given 
responsibility. 


156  ENCEPHALOPSYCHOSES 


Coexistence  of  hysterical  and  organic  symptoms 
in  two  cases  of  mine  explosion. 


Cases  116  and  117.     (Smyly,  April,  191 7.) 

A  soldier  was  blown  up  by  a  mine  and  rendered  uncon- 
scious. Upon  recovery  of  consciousness,  he  was  dumb, 
unable  to  work,  very  nervous,  paralyzed  as  to  left  arm  and 
leg.  The  paralysis  improved  so  that  in  the  hospital  at  home 
the  patient  became  able  to  get  about.  However,  he  threw 
his  legs  about  in  an  unusual  fashion.  Several  months  later, 
the  patient  was  much  improved. 

Shortly,  however,  there  was  a  relapse.  Transferred  to  a 
hospital  for  chronic  cases,  the  patient  was  unable  to  walk 
without  assistance  on  account  of  complete  paralysis  of  the 
leg.  Insomnia,  general  tremor,  and  a  bad  stuttering  de- 
veloped, with  a  habit  of  starting  in  terror  at  the  slightest 
noise. 

Hypnotic  treatment  was  followed  by  almost  complete  dis- 
appearance of  the  tremor.  The  patient  began  to  sleep  six  or 
seven  hours  a  night ;  nervousness  diminished,  and  the  stutter- 
ing slowly  improved ;  but  neither  the  paralysis  nor  the  anes- 
thesia of  the  left  leg  was  affected  by  suggestion.  The  leg 
remained  cold,  livid,  anesthetic,  and  flaccidly  paralyzed  to 
the  hip.  Though  a  slight  improvement  has  since  been  pro- 
duced by  faradization,  the  patient  still  can  walk  only  with 
assistance. 

A  man  was  Injured  in  1906  by  the  fall  of  a  heavy  weight  on 
his  back.  In  19 14  he  went  to  France  as  a  soldier,  and  eight 
months  later  was  hurled  into  a  shell  hole  so  that  his  back 
struck  the  edge.  He  was  rendered  unconscious.  Upon 
recovery  of  consciousness,  the  right  leg  was  found  to  be 
swollen,  and  there  were  severe  pains  in  the  legs  and  back. 

Since  return  home  the  patient  had  gone  from  one  hospital 
to  another,  for  the  most  part  unable  to  walk,  suffering  from 
agonizing  pain  in  the  head  and  eyes,  unable  to  sleep,  and  in 
the  night  subject  to  horrible  waking  dreams. 


ENCEPHALOPSYCHOSES  1 57 


MINOR   SIGNS   OF   ORGANIC   HEMIPLEGIA 

(LHERMITTE) 

I.    Hyperextension  of  forearm  (hypotonia). 
II.    Platysma  sign:   Contraction  absent  on  paralyzed  side. 

III.  Babinski's  flexion  of  thigh  on  pelvis  (spontaneous,  upon  suddenly 

throwing  seated  subject  into  dorsal  decubitus). 

IV.  Hoover's  sign:    Complementary  opposition  (on  request  to  raise 

paralyzed  arm,  presses  opposite  arm  strongly  against  mattress). 

V.    Heilbronner's  sign  of  the  broad  thigh  (hypotonia). 

VI.    Rossolimo's  sign :   flexion  of  toes  on  slight  percussion  of  sole. 

VII.    Mendel-Bechterew  sign:  flexion  of  small  toes  on  percussion  with 
hammer  of  dorsal  surface  of  cuboid  bone. 

VIII.   Oppenheim's  sign  (extension  of  great  toe  on  deep  friction  of  calf 
muscles;   or  Schaefer,  or  Gordon  (on  pinching  tendo  Achillis). 

IX.  Marie-Foix  sign:  withdrawal  of  lower  leg  on  transverse  pressure 
of  tarsus  or  forced  flexion  of  toes,  even  when  leg  is  incapable 
of  voluntary  movement. 


Chart  6 


158  ENCEPHALOPSYCHOSES 

At  first  able  only  to  bring  himself  to  an  upright  position 
and  to  rush  a  few  steps,  he  later  acquired  considerable 
control  of  his  feet  and  legs  through  crutches.  The  Insomnia 
persisted. 

Smyly  regards  this  case,  like  Case  116,  as  more  neurological 
than  mental. 

Re  organic  neurology,  much  of  great  value  has  been  re- 
ported. 

Sargent  and  Holmes  say  that,  contrary  to  expectation, 
there  have  been  few  war  cases  of  bad  sequelae  of  cerebral 
Injuries,  such  as  Insanity  and  epilepsy.  During  early  stages, 
after  infection  of  the  head  wounds,  there  is  dulness  and 
amnesia,  Irritability  and  childishness,  —  symptoms  which 
disappear  during  and  after  repair  of  the  wounds.  Mental 
disorder  requiring  Internment  is  surprisingly  rare.  During 
12  months  only  eight  cases  were  transferred  from  the  head 
hospital  in  a  year  to  the  Napsbury  war  hospital,  where  cases 
of  Insanity  attributable  to  the  service  are  sent;  and  In  but 
two  of  these  could  the  persisting  mental  symptoms  be  at- 
tributed to  head  Injury. 

Col.  F.  W.  Mott  confirms  the  opinion  of  Col.  Sargent  and 
Col.  Holmes,  remarking  that  from  all  the  London  County 
Council  Asylums,  only  one  case  of  Insanity  associated  with 
gunshot  head  wound  had  been  admitted,  and  that  this  was 
one  of  a  Belgian  who  died  from  septic  Infection  of  the  cerebral 
ventricles.  Yet  all  cases  of  insanity  In  Invalided  soldiers 
belonging  to  the  London  County  Council  area  (about  one- 
seventh  of  the  population  of  the  United  Kingdom)  are  trans- 
ferred to  these  asylums. 

Again  Sargent  and  Holmes  point  out  that  both  generalized 
and  Jacksonian  epileptiform  seizures  are  comparatively  rare 
In  patients  sufiferlng  from  recent  head  wounds;  even  con- 
vulsions in  later  stages  have  been  as  yet  less  common  than  was 
feared.  Thus,  after  evacuation  to  England,  fits  occurred  in 
37  (6  per  cent)  of  610  cases  with  complete  notes,  and  In  only 
eleven  of  these  37  cases  were  the  convulsions  frequent. 
Sargent  and  Holmes  remark,  however,  that  the  practice  of 
giving  bromides  regularly  to  all  serious  cranial  Injuries  until 
the  wound  is  healed,  and  for  some  months  afterwards,  seems 


ENCEPHALOPSYCHOSES  159 

advisable.  In  33  of  the  37  convulsive  cases  there  have  been 
severe  compound  fractures  of  the  skull,  and  in  four  of  these 
a  missile  was  still  present  in  the  brain.  Five  secondary- 
operations  were  performed  with  good  results,  after  drainage 
of  small  abscesses  in  two  and  removal  of  spicules  of  bone  in 
three.  The  In-patient  and  Out-patient  records  of  the  Na- 
tional Hospital  for  the  Paralyzed  and  Epileptic  were  searched 
for  epileptics  already  discharged  from  the  army,  but  notes  of 
but  two  patients  attending  this  hospital  for  epilepsy  were 
found. 

As  for  other  neurological  complications  aside  from  septic 
infection  and  hernia  formation,  there  are  a  few  subjective 
symptoms  that  may  necessitate  the  invaliding  of  soldiers. 
The  most  common  of  these  is  headache,  usually  in  the  form 
of  a  feeling  of  weight,  pressure,  or  throbbing  in  the  head, 
which  headache  is  Increased  by  noise,  fatigue,  exertion,  or 
emotion.  Attacks  of  dizziness  also  occur,  and  nervousness 
or  deficient  control  over  emotions  and  feelings.  Changes  of 
temperament  are  found  in  some  soldiers,  who  become  de- 
pressed, moody,  irritable,  or  emotional,  and  unable  to  con- 
centrate attention. 

Foix,  under  the  direction  of  P.  Marie,  worked  upon  aphasia 
in  100  cases,  reporting  results  at  a  surgical  and  neurological 
meeting.  May  24,  19 16,  in  Paris.  Only  lesions  on  the  left 
side  of  the  brain  have  produced  important  and  lasting  speech 
disorder,  although  lesions  on  the  left  side  may  leave  behind 
them  a  little  dysarthria  or  difficulty  in  finding  words  in  con- 
versation. It  is,  of  course,  hard  to  tell  speech  disorder  from 
stupor  or  clouding  of  consciousness.  Foix  notes  certain 
specialties  in  speech  defect  according  to  which  region  of  the 
left  brain  is  affected. 

First:  (Prefrontal  lesions  produce  a  transient  dysarthria, 
lasting  but  a  few  weeks,  and  right-sided  prefrontal  lesions 
produce  just  as  much  disorder. 

Occipital  lesions  produce  no  speech  disorder. 

Second:  Patients  with  right-sided  hemianopsia  due  to 
lesions  of  occipital  regions  were  not  aphasic  and  could  read 
or  write  perfectly.  Lesions  of  the  left  visual  centers  certainly 
do  not  affect  reading.     If,  however,  the  injury  is  not  to  the 


l60  ENCEPHALOPSYCHOSES 

visual  centers,  but  is  upon  the  lateral  part  of  the  occipital 
lobe,  then  alexic  phenomena  appear,  and  these  the  more  the 
lesion  approaches  the  temporal-parietal  region. 

Third :  Central  convolutional  lesion  produces  a  variety  of 
disorders  according  to  the  site  and  extent  of  the  lesion. 
There  is  no  aphasia  with  the  crural  monoplegia  due  to 
superior  paracentral  disorder.  But  slight  aphasic  disorder 
accompanies  the  brachial  monoplegia  of  middle  central  lesion, 
though  writing,  reading,  and  calculation  are  slightly  affected, 
and  the  more  so  the  more  the  lesion  extends  posteriorly  to  the 
stereognostic  regions.  The  lower  down  in  the  precentral 
region  the  lesion  appears,  the  more  likely  is  the  Broca  syn- 
drome to  be  observed.  But  if  the  hemiplegia  is  chiefly  a 
brachial  monoplegia,  the  aphasic  disorder  may  remain  slight, 
involving  reading,  writing,  understanding  of  words,  the 
spoken  word,  articulation,  and  calculation. 

jFourth :  Lesions  of  the  lateral-frontal  region  produce  more 
or  less  marked  aphasic  disorder,  just  as  do  those  of  the  in- 
ferior part  of  the  precentral  gyrus.  This  aphasia  is  more  apt 
to  occur  when  the  wound  is  deep.  However,  no  case  of 
permanent  aphasia  has  been  observed  in  cases  of  lesion  of  the 
lateral-frontal  region  (termed  in  Foix's  nomenclature,  the 
precentral  region,  but  referring  to  the  tissues  in  front  of  the 
precentral  (or  ascending  frontal)  gyrus  of  the  more  familiar 
nomenclature).  Almost  absolute,  or  absolute,  anarthria  fol- 
lows the  wound,  and  the  patient  is  hemiplegic.  This  hemi- 
plegia may  last  from  ten  days  to  two  or  three  months.  After 
a  time  there  is  no  longer  more  than  a  slight  dysarthria,  and 
writing  becomes  good  again;  reading  remains,  perhaps,  a 
little  difficult.  A  complete  or  almost  complete  cure  is  the 
rule. 

Fifth:  When  the  retrocentral  region  is  injured,  various 
aphasic  syndromes  appear.  The  retrocentral  region  is  the 
parietal-temporal  lobe  except  the  superior  part  of  the  parietal 
lobe  and  the  anterior  part  of  the  temporal  lobe,  which  latter 
two  regions  when  injured  do  not  allow  any  marked  aphasic 
disorder.  Lesions  of  the  middle  or  posterior  temporal  region 
are  particularly  important  for  speech,  and  produce  more 
marked  disorder  than  lesions  of  the  angular  gyrus  or  the 


ENCEPHALOPSYCHOSES  l6l 

supramarglnal  gyrus.  At  first,  words  cannot  be  spoken,  for 
a  period  of  a  fortnight  to  three  months.  Speech  returns 
progressively,  with  an  increased  power  of  comprehension. 
At  the  same  time,  the  patients  begin  to  read  and  write.  But 
there  is  no  further  spontaneous  progress  after  a  period  of 
six  or  eight  months,  and  then  special  reeducation  must  be 
started.  These  speech  disorders  of  retrocentral  (parietal- 
temporal)  origin  are  either  aphasic  syndromes  or  slight 
remains  of  psychical  disorders,  or  again,  a  disorder  practically 
limited  to  alexia.  The  true  aphasic  syndromes  concern  the 
spoken  word,  understanding  the  words,  writing,  and  calcula- 
tion. The  disorder  is  not  especially  dysarthric  and  consists 
particularly  in  loss  of  vocabulary.  It  might  be  called  an  am- 
nestic aphasia  (Pitres).  These  cases  have  well-marked  intel- 
lectual disorder  and  their  power  of  calculation  is  especially 
poor.  As  to  the  aphasic  traces,  w^hich  are  more  important 
to  understand  than  they  are  extensive  in  point  of  fact,  they 
relate  particularly  to  calculating  power,  to  vocabulary  (slow- 
ness in  finding  words),  and  to  reading  (reading  without  com- 
prehension). As  to  the  cases  of  alexia,  these  are  cases  of 
lesions  of  the  posterior  part  of  the  parietal-temporal  lobe,  and 
are  usually  accompanied  by  a  hemi-  or  a  quadrantanopsia. 

To  sum  up,  cases  with  central  lesions  (precentral  and  post- 
central gyrus)  have  hemiplegia  and  a  Broca  aphasia  without 
much  tendency  to  cure.  Cases  with  lesions  anterior  to  the 
central  convolutions  have  a  transient  anarthria  and  their 
recovery  is  ordinarily  complete.  Cases  with  retrocentral 
lesions  have  an  aphasia  suggestive  of  Wernicke's  aphasia,  and 
ordinarily  leave  behind  them  extensive  defects  in  intelligence 
and  language.  These  cases  should  be  taken  account  of  from 
the  standpoint  of  compensation,  since  they  are  much  worse 
off  for  work  than  many  cases  with  amputations ;  and  though 
their  disorder  looks  slight,  it  quite  interferes  with  working  at 
a  trade.  From  the  point  of  view  of  military  effectiveness, 
the  retrocentral  cases  are  not  very  good  soldiers,  and  espe- 
cially not  good  officers,  as  they  do  not  understand  commands 
completely. 


1 62  ENCEPHALOPSYCHOSES 


Neuropsychiatric  phenomena  in  rabies. 


Case  ii8.  (Grenier  de  Cardenal,  Legrand,  Benoit, 
September,  1917.) 

A  farmer,  34,  mobilized  in  veterinary  work,  fell  sick  at  a 
station  for  sick  horses,  April  25,  191 7.  He  breakfasted  well, 
drank  coffee,  and  went  to  the  ahreuvoir  at  eleven  o'clock.  He 
told  his  mates  that  he  felt  bad  in  his  head.  He  fainted  over 
a  table  at  the  eating  house,  refused  to  eat  or  drink.  At  noon 
he  went  out  into  the  court,  vomited  and  went  to  lie  down. 
A  physician  thought  he  was  suffering  from  angina  because 
of  the  pronounced  dysphagia.  He  entered  the  hospital 
at  eleven  o'clock  at  night  on  the  25th.  He  was  found  next 
morning  on  his  back,  with  a  fixed  and  haggard  look,  crimson 
face,  masseter  and  phalangeal  spasm  at  times.  Respiration 
irregular,  interrupted  by  moans.  The  pulse  would  go  up  to 
120  during  agitation  and  then  go  down  to  50  as  soon  as  the 
patient  lay  down  again.  Pupils  slightly  dilated  and  unequal. 
As  the  patient  came  from  a  sick  horse  depot,  the  first  question 
was  that  of  tetanus,  suggested  somewhat  by  the  jactitation 
of  the  limbs  and  the  trismus.  A  violent  headache  began  and 
the  patient  cried  out,  "  My  head!  My  head!"  Painful 
vomiting  movements,  with  very  slight  bilious  material. 
Convulsive  movements  increased.  The  pulse  was  slow.  The 
diagnosis  "  meningitis  "  was  suggested,  despite  the  absence  of 
fever  and  the  absence  of  Kernig's  sign.  Lumbar  puncture 
gave  limpid  fluid  with  a  normal  lymphocytosis,  without  in- 
crease of  albumin  or  reducing  substance.  The  bacteriolog- 
ical smear  and  culture  were  negative. 

Soon  another  sort  of  symptoms  appeared.  The  patient 
would  rise,  cry  out,  threaten  his  neighbors.  He  was  calmed 
with  morphine.  There  were  periods  of  excitement  alternating 
with  periods  of  calmness,  during  which  he  would  reply  sharply 
but  accurately,  being  somewhat  vexed  by  the  questions,  and 
would  walk  up  and  down  without  offering  a  word.  When  a 
glass  of  water  was  offered  to  him,  as  soon  as  his  glance  met 
the  glass  his  eyes  expressed  fear.     He  drew  back  in  repulsion 


ENCEPHALOPSYCHOSES  1 63 

and  cried  out  in  terror.  When  the  liquid  was  out  of  his  sight 
the  hydrophobic  spasm  ceased.  This  hyperesthesia  of  the 
sensorium  was  so  intense  that  the  mere  sight  of  the  shining 
glassware  of  the  laboratory  brought  out  a  sharp  crisis. 

He  was  sent  that  evening  to  the  neuropsychiatric  center, 
walking  jerkily  and  as  if  slightly  drunk,  with  a  number  of 
small  gesticulations  and  murmurings.  He  was  immedi- 
ately isolated,  undressed  himself  and  went  to  bed.  He  did 
not  move  in  his  bed,  and  seemed  to  sleep.  The  next  day  he 
got  up,  dressed  and  had  a  small  spell  of  excitement,  but  was 
quiet  enough  on  the  medical  visit,  though  the  floor  was  soiled 
with  urine  and  vomitus  and  the  clothing  was  in  disorder. 
He  now  had  a  pronounced  phase,  deep  sunk  eyes,  drawn 
features  and  anxious  look;  dilated  pupils  and  an  expression 
of  mixed  fear  and  anger.  His  breathing  was  hard  and  he 
kept  his  hand  on  his  heart.  He  was  oriented.  He  suddenly 
rose  and  said,  "  I  am  thirsty."  A  glass  of  milk  was  given 
him.  He  hesitated  a  moment,  plunged  his  mouth  and  hands 
into  it  and  aspirated  the  drink  without  making  any  swallow- 
ing movements.  He  pushed  away  the  glass,  spat  a  little,  and 
vomited  a  small  quantity  of  a  black  liquid.  Then  followed 
an  anxious  crisis,  and  he  fell  upon  his  side,  absolutely  immo- 
bile, without  breathing  for  a  few  seconds.  Again  in  the 
sitting  posture,  he  was  taken  with  contractions  of  the  limbs 
and  face.     The  tendon  reflexes  were  at  this  time  normal. 

A  quarter  of  an  hour  later  the  attendant  found  him  dead, 
in  the  sitting  posture,  leaning  against  the  wall,  mouth  open, 
arms  dependent,  hands  extended,  pupils  dilated  —  a  death 
in  syncope.  The  brain  was  found  congested.  There  was  a 
slight  effusion  of  blood  over  the  posterior  aspect  of  the  brain. 
There  were  no  hemorrhages  or  softenings  in  the  brain  sub- 
stance. The  muscles  were  of  a  dark  red  to  black.  The  ad- 
herent lungs  were  very  slightly  congested  at  the  base.  The 
stomach  contained  a  quarter  of  a  liter  of  black,  inodorous 
fluid  in  which  there  was  much  bile  and  little  blood.  There 
were  numerous  small  hemorrhages  of  the  mucosa  near  the 
great  curvature.  The  spleen  was  large,  the  liver  congested. 
The  Pasteur  Institute  confirmed  the  diagnosis  of  rabies. 
There  is  no  history  of  the  man's  having  been  bitten  by  a  dog. 


1 64  ENCEPHALOPSYCHOSES 


Tetanus:  Psychosis. 


Case  119.     (LuMifeRE  and  Astier,  1917.) 

A  soldier  wounded  May  18,  191 6,  was  given  antitetanic 
serum  May  26th.  The  wounds  healed,  but  on  June  16,  that 
is,  29  days  after  the  trauma,  contractures  began,  at  first  lo- 
calized. There  had  been  numerous  wounds  of  legs  and  scro- 
tum by  shell  fragments  and  the  contractures  were  limited  to 
the  right  leg  and  scrotum.  There  was  no  trismus  or  any 
lumbar  symptom. 

During  the  next  few  days  the  contractures  became  general, 
the  temperature  rose,  a  shell  fragment  was  found  by  X-ray 
at  the  root  of  the  thigh  and  was  surgically  extracted.  B. 
tetani  was  found  upon  inoculation  of  media  with  material 
from  the  shell  fragment.  Persulphide  of  soda  and  anti- 
tetanic  serum  90  cc.  in  three  days  were  given  intravenously. 
The  temperature  fell  and  the  general  health  was  greatly  im- 
proved. July  6,  hallucinations  and  terrors,  worse  at  night, 
set  in.  The  man  believed  himself  surrounded  by  flames, 
that  daggers  were  being  plunged  into  his  old  wounds,  that 
his  hair  was  being  pulled.  These  symptoms  lasted  a  fort- 
night only,  whereupon  the  patient  recovered. 

This  case  and  six  others  accompanied  by  cerebral  dis- 
turbances all  recovered,  and  all  the  patients  retained  a  per- 
fect memory  of  their  delirium  and  of  their  hallucinations. 

The  chronological  distribution  of  these  cases  was  odd. 
One  case  was  found  early  in  the  war;  then  no  other  cases  of 
cerebral  disorder  presented  themselves  until  the  group  ob- 
served at  the  end  of  191 6.  Besides  flames  and  daggers, 
zoopsia  was  several  times  observed.  One  of  the  cases  showed 
these  symptoms  without  having  been  given  antitetanic  serum. 

Re  tetanus  in  the  war,  see  in  the  Collection  Horizon  a  book 
by  Courtois-Suffit  and  Giroux  on  Les  formes  anormales  du 
tetanos. 


ENCEPHALOPSYCHOSES  1 6; 

Tetanus  fruste  versus  hysteria. 


Case  120.     (Claude  and  Lhermitte,  191 5.) 

Claude  and  Lhermitte  describe  a  condition  of  tetanos 
fruste.  The  neck  was  absolutely  rigid.  The  patient  had 
not  been  wounded  in  any  way  and,  being  regarded  as  a  pure 
neuropath,  was  sent  to  the  Centre  Xeurologique  at  Bourges. 

The  differential  diagnosis  lay  between  true  tetanus  and  the 
hysterical  pseudotetanus  or  pseudomeningitis.  In  pseudo- 
tetanus  there  is  a  contracture  of  the  superficial  and  deep 
neck  muscles,  especially  the  trapezii,  sternomastoid,  and 
deep  muscles.  The  condition  somewhat  suggests  that  of 
acute  meningitis  or  tetanus,  and  especially  suggests  tetanus 
because  it  is  often  associated  with  masseter  contracture 
(hysterical  trismus).  The  head  is  immobile,  stiff,  and  in- 
clined backward;  eyes  directed  above,  throat  slightly  promi- 
nent. Upon  attempts  to  move  the  head,  intense  pain  occurs. 
The  pain  and  contracture  sometimes  even  suggest  a  sub- 
occipital Pott's  disease.  This  form  of  hysterical  pseudo- 
tetanus  is  of  sudden  onset,  as  a  rule  following  burial  in  a 
trench  or  else  contusion,  or  a  slight  wound  in  the  cervical 
region.  Pressure  on  the  spinous  processes  produces  no  pain, 
nor  does  a  blow  upon  the  head;  and  an  X-ray  examination 
will  definitely  eliminate  the  hypothesis  of  Pott's  disease. 

To  return  to  the  Claude-Lhermitte  case  of  limited  true 
tetanus:  It  showed  marked  modifications  in  the  tendon  and 
bone  reflexes.  Upon  percussion  of  the  zygoma,  of  the  occiput, 
or  of  the  clavicle,  there  was  a  marked  further  contraction  in 
the  contractured  muscles.  Although  there  was  no  apparent 
spasticity  in  the  legs,  there  was  an  ankle  clonus  and  a  bilateral 
patella  clonus,  combined  with  a  distinct  exaggeration  of  all 
bone  and  tendon  reflexes.  In  such  cases  also  there  is  hyper- 
excitability  of  the  nerves  and  muscles  to  faradic  and  galvanic 
currents. 


l66  ENCEPHALOPSYCHOSES 

An  officer's  letter  concerning  local  tetanus. 


Case  121.     (TuRRELL,  January,  1917.) 

The  following  letter  from  an  officer  who  had  had  local 
tetanus  [and  was  treated  by  Turrell  by  ionization  Dec.  6 
and  7,  1 91 5,  by  diathermia  Dec.  7  to  22,  and  occasionally  by 
static  breeze  ionization  and  chlorine  ion  to  relieve  contrac- 
tions from  Dec.  29,  191 5,  to  Feb.  4,  191 6.  The  tetanus  was 
in  the  muscles  of  the  legs.  Of  course  diathermia  is  a  purely 
symptomatic  treatment  and  does  not  replace  antitoxin  serum 
or  other  specific  treatment;  thus  its  effect  in  relieving  the 
contractions  of  local  tetanus  is  precisely  like  its  effect  in  the 
treatment  of  sciatic  neuritis  or  lumbago. 

November  15,  19 16. 
"  Dear  Major  Turrell, 

"  I  have  been  meaning  to  write  to  you  for  some 
time,  as  I  knew  you  would  be  interested  to  hear  how  I 
was  getting  on.  Your  letter  has  just  been  received,  and 
I  am  only  too  happy  to  give  you  any  information  I  can 
with  regard  to  my  leg.  I  was  wounded  in  the  left  leg 
on  October  13,  191 5,  by  high  explosive  shell,  and  arrived 
at  Oxford  on  October  22.  There  was  no  operation  as 
the  surgeon  in  charge  did  not  consider  it  advisable  to 
remove  the  pieces  of  shell :  my  leg  seemed  to  be  getting 
better,  and  after  about  a  month  I  was  able  to  hobble 
round  with  sticks.  My  foot  at  this  time  used  to  swell 
a  great  deal  towards  night,  and  the  foot  seemed  then 
to  gradually  stiffen  up  with  violent  pains  at  intervals, 
this  gradually  spread  up  the  whole  leg  to  about  the 
knee,  and  I  was  compelled  to  take  to  my  bed  again. 
The  pain  at  times  was  very  bad,  similar  to  a  very  bad 
attack  of  cramps,  and  then  my  leg  became  rigid  and 
stiff,  and  at  other  times  used  to  get  horrible  jumps  and 
it  was  impossible  to  keep  it  still,  and  whenever  the  doc- 
tor or  nurse  looked  at  it  it  used  to  stiffen  up  at  once. 
The  night  seemed  to  be  the  worst,  and  consequently 
I  got  very  little  sleep.  I  often  had  to  get  up  in  the 
middle  of  the  night  on  crutches  to  try  and  obtain 
relief,  my  leg  was  so  cramped  and  sore.  It  was  about 
this  time  that  you  first  visited  me  and  prescribed  a 
course  of  electric  treatment  for  my  leg,  and  I  shall  never 
be  able  to  thank  you  enough  for  the  relief  it  gave  me. 


ENCEPHALOPSYCHOSES  1 6/ 

I  cannot  remember  the  names  of  the  different  treat- 
ments, but  the  first  one  —  diathermy,  or  heat  pads  — 
certainly  relieved  the  pain,  and  after  the  first  two  or 
three  visits  to  you  I  got  immense  relief.  I  never  looked 
back  after  this,  and,  although  the  progress  was  slow,  I 
gradually  lost  all  pain  and  was  able  to  get  sleep  at  night. 
The  nervous  jumps  slowly  disappeared  and  my  leg 
became  gradually  normal  except  for  contraction  of  the 
tendons.  I  was  unable  to  straighten  my  ankle  or  knee, 
and  it  was  thought  at  one  time  that  my  tendo  Achillis 
would  have  to  be  severed.  Gradually  the  knee  straight- 
ened and  I  was  able  to  get  my  heel  to  the  ground.  I 
was  for  some  time  on  crutches,  and  was  able  to  leave  the 
hospital  on  February  5,  19 16,  walking  with  sticks.  .  .  . 
I  am  now  able  to  walk  comfortably,  but  am  unable  to 
flex  the  ankle  more  than  at  right  angle  to  my  leg.  The 
circulation  is  not  very  good,  and  I  feel  anything  tight 
round  my  calf.  I  am  still  getting  Boards,  and  have  not 
been  passed  fit  for  overseas  yet." 


VI.   SOMATOPSYCHOSES 
(THE  SYMPTOMATIC,   NON-NERVOUS,   GROUP) 


Dysentery:  Psychosis. 


Case  122.     (LoEWY,  November,  1915.) 

Out  of  a  large  number  of  dysentery  patients,  many  of 
whom  had  very  serious  symptoms,  but  one  of  Loewy's 
patients  became  psychotic.  Loewy  in  fact  had  discharged 
this  one  as  normal,  and  he  had  been  put  on  the  wagon  train 
(no  opium  or  alcohol)  to  go  to  a  sanatorium.  As  the 
fighting  shifted,  the  sanatorium  site  changed  and  could  not 
be  reached  with  the  wagon.  Finally,  the  wagon  train  met 
the  battalion  once  more  and  Loewy  was  told  that  the  man 
was  "  dying."  At  this  time  he  was  afebrile,  without  collapse 
symptoms,  with  a  strong  and  normally  frequent  pulse,  and 
with  few  signs  of  exhaustion.  Yet  the  guard  had  thought 
that  he  looked  moribund.  Both  upper  eyelids  were  drawn 
rigidly  up  but  conveyed  a  different  impression  from  that  in 
maniacal  or  anxious  conditions.  The  expression  was  that 
of  staring  astonishment,  helplessness,  and  apathetic  lack  of 
orientation.  The  patient  recognized  Loewy,  spoke  to  him 
as  "  Herr  Doctor,"  said  he  was  doing  quite  well;  he  was 
found  to  be  well  oriented.  There  was  no  fabricating  tend- 
ency even  as  to  the  number  of  stools  (although  Loewy  had 
noted  such  in  bad  dysenteries  of  the  Shiga-Kruse  type). 
He  was  apparently  hard  of  hearing,  as  if  at  the  beginning 
of  a  typhoid  fever.  He  showed  a  retardation  in  his  intake  of 
ideas,  and  his  voice  in  answering  sounded  absent-minded. 
There  was  an  expression  of  absent-mindedness,  and  the 
patient  seemed  markedly  unconcerned  about  his  health,  the 
direction  of  the  journey,  the  terrible  rain,  etc.  These  phe- 
nomena are  attributed  by  Loewy  to  attention  disorder. 

The  patient  had  been  out  of  reach  of  fire  for  days.  Loewy 
reports  the  case  as  one  of  beginning  amentia  or  as  an  ex- 
hausted state  resembling  a  Korsakow  condition,  recalling  one 

of  emotional  hyperesthetic  weakness  (BonhoefTer). 

16S 


SOMATOPSYCHOSES  1 69 


Typhoid  fever :  Hysteria. 


Case  123.     (Sterz,  December,  19 14.) 

A  soldier  entering  hospital  for  typhoid  fever,  October  2, 
1914,  was  discharged  to  another  hospital  and  again,  Novem- 
ber 10,  to  a  hospital  for  nervous  disease.  The  typhoid  was 
serious  and  complicated  by  delirium.  After  defervescence, 
the  patient  was  weak  and  could  not  stand  or  walk,  especially 
on  account  of  pains  and  weakness  in  the  left  leg.  Sometimes 
he  had  had  pains  in  the  sacrum  and  left  hip.  He  complained 
of  tinnitus,  deafness,  dizziness,  headache.  He  said  he  had 
fallen  from  a  cart,  had  been  sick  for  three  months,  since  which 
time  he  had  been  under  medical  treatment  for  his  present 
condition.     He  had,  he  said,  been  given  a  small  pension. 

The  gait  disorder  sometimes  amounted  to  a  real  astasia- 
abasia.  The  left  leg  became  stiff  and  was  dragged  behind. 
There  was  a  paresis  demonstrable  in  dorsal  decubitus,  of  the 
left  side,  especially  of  the  leg,  without  atrophy.  There  was 
a  hypesthesia  of  the  whole  left  side  of  the  body,  with  the 
exception  of  the  head.  Hyperesthesia  of  the  left  leg,  hip 
and  upper  sacrum.  The  left  corneal  reflex  was  diminished. 
Moody,  hypochondriacal,  lachrymose.  The  general  attitude 
of  the  patient  was  affected  and  theatrical.  Paradoxical 
innerv^ations  were  frequently  found  on  test.  There  was  no 
neurological  disorder  except  for  the  absence  of  the  right 
Achilles  jerk. 

The  absence  of  this  Achilles  jerk  may  be  regarded  as  a 
residuum  of  the  previous  accident.  The  localization  of  the 
pains  points  to  a  neurotic  lumbosacral  plexus  disorder  on  the 
left  side.  Superimposed  upon  this  picture  are  the  hysterical 
phenomena.  The  typhoid  fever  and  its  attendant  neuritis 
are  therefore  to  be  interpreted  as  the  liberating  factor  for  a 
severe  hysteria  in  a  subject  already  disposed  to  such  symp- 
toms through  previous  accident. 


1 70  SOMATOPSYCHOSES 

Dementia  praecox  versus  post-typhoidal  encephalitis. 


Case  124.     (NoRDMAN,  June,  1916.) 

A  butcher,  29  (aunt  insane,  sister  melancholy,  one  child 
stillborn,  deformed),  had  had  several  days  convulsions  at 
eight;  went  through  military  service  without  incident;  was 
at  the  Marne  and  was  evacuated  October  19,  1914,  with  ty- 
phoid fever,  —  a  severe  fever  with  a  delirium  prolonged  into 
the  last  weeks.  Three  months  convalescent  leave  was  given, 
passed  at  Paris  with  the  man's  aunt,  but  he  had  become 
strange.  One  day  he  wanted  to  strangle  neighbors  of  German 
origin ;  another  day  departed  for  Dunkirk  and  then  returned, 
having  lost  all  his  documents. 

February,  191 5,  he  went  back  to  the  front,  did  strange 
things  and  was  soon  evacuated  to  Tarascon.  In  April  he 
went  back  to  his  depot;  May  18,  to  the  hospital  at  Rennes 
for  erythema.  June  15,  he  was  given  15  days  in  prison 
for  setting  off  a  cannon  too  quickly  and  then  running  off 
through  the  fields.  August  11,  he  was  interned  at  Rennes 
for  stealing  a  priest's  cap.  September  12,  two  months  con- 
valescence. December  10,  headaches.  Back  to  Rennes  Jan- 
uary 14,  February  18,  Val-de-Grace,  then  Maison  Blanche. 

Here  he  was  found  sometimes  sad,  immobile;  at  other 
times  laughing  and  singing.  He  was  very  irritable  on  small 
occasion.  Once  on  leave  he  had  a  fugue  with  complete 
amnesia,  though  alcohol  may  account  for  the  latter.  His 
memory  was  vague,  especially  for  his  crimes  and  for  recent 
events.  He  was  emotional,  indifferent  even  in  the  presence 
of  his  wife  or  aunt.  Sexual  indifference.  He  often  com- 
plained of  his  head,  saying  that  he  felt  it  blocked  and  that  he 
could  not  think.  The  headache  was  frontal  and  would  last 
several  hours.  The  man  would,  however,  not  complain 
spontaneously.     He  was  physically,  in  general,  negative. 

This  case  might  possibly  be  due  to  a  post-typhoidal  encepha- 
litis, but  Nordman  believes  rather  that  it  is  a  case  of  dementia 
praecox.  Perhaps  the  convulsions  at  eight  produced  a  slight 
brain  lesion,  brought  to  an  issue  by  the  typhoid  fever. 


SOMATOPSYCHOSES  1 71 

Paratyphoid  fever :  Psychosis  outlasting  fever. 


Case  125.     (Merklen,  December,  1915.) 

A  Breton  farmer,  34,  had  paratyphoid  alpha.  Admitted 
to  hospital  September  3,  191 5,  he  had  headache,  anorexia, 
asthenia,  coated  tongue  and  tense  abdomen,  algosuria;  later, 
abdominal  swelling,  borborygmi  in  the  right  ihac  fossa,  rose 
spots,  dicrotism,  albuminuria,  bronchitic  rales.  The  disease 
was  severe,  and  was  complicated  by  sacral  decubitus  and 
ran  a  month. 

At  first  somnolent,  September  8th  the  patient  went  into  a 
state  of  mental  excitement  with  agitation  and  delirium.  He 
got  out  of  bed,  cried  out,  sang,  talked  to  his  neighbors,  com- 
plained that  his  papers  (colis)  had  been  stolen,  as  well  as  his 
watch  and  tobacco;  that  his  horses'  hoofs  had  been  injured, 
and  the  like. 

He  grew  calmer  in  a  few  days,  and  now  no  longer  tried  to 
get  up,  remaining  inert  in  his  bed.  The  occupation  delirium 
persisted  —  he  was  not  being  paid  what  he  owed,  and  the 
like.  He  had  hallucinations;  looked  for  scissors,  and  one  day 
said,  "  Here  they  are! "  At  intervals  he  appeared  lucid  and 
responded  appropriately  to  questions. 

The  fever  dropped  and  the  paratyphoid  disease  appeared 
past,  but  the  mental  state  remained  for  three  weeks  without 
change,  having  the  same  periods  of  lucidity  when  he  would  be 
regarded  as  cured,  but  falling  again  forthwith  into  his  post 
oniric  ideas.  He  was  soon  sent  to  a  convalescent  hospital 
and  was  not  wholly  well  for  another  month. 


172  SOMATOPSYCHOSES 

Psychopathic  taint  brought  out  by  paratyphoid  fever. 


Case  126.     (Merklen,  December,  191 5.) 

A  soldier,  31,  was  a  victim  of  paratyphoid  alpha,  entering 
hospital  October  21,  191 5,  with  the  usual  symptomatology: 
fever,  asthenia,  headache,  abdominal  swelling,  tongue  coated 
and  red  along  its  edges,  diarrhoea.  After  admission  he 
passed  into  a  deep  toxic  state. 

He  woke  up  in  the  night  with  a  cry,  got  up  afraid,  and  re- 
fused to  go  back  into  his  own  bed.  He  was  mute,  except  for 
curses  addressed  to  the  nurses.  After  two  hours  he  went  to 
bed  and  to  sleep.  Next  day  he  sat  quietly  with  a  depressed 
look,  occasionally  groaning  deeply,  talking  in  brief  phrases 
about  his  anxiety,  wanting  his  wife  telephoned  to,  saying 
that  he  would  not  see  his  children,  was  going  into  the  four 
planks,  and  the  like. 

This  situation  lasted  about  a  week.  He  became  afraid  of 
medicines  and  thought  he  had  been  poisoned,  saying  that  he 
would  rather  be  shot  than  poisoned  and  complaining  that, 
though  he  had  served  France  for  fourteen  months,  they  now 
wanted  to  kill  him.  In  the  night  time  he  was  agitated.  He 
gave  vent  to  cries,  and  threats,  but  this  delirious  state  rapidly 
decreased  and  he  became  calm  the  night  of  September  27th. 
The  upper  extremities  showed  a  tendency  to  catatonia. 
From  this  time  forth,  during  the  remaining  month,  the  pa- 
tient was  immobile,  mute,  fearful,  and  mistrusting,  depressed 
and  always  wore  a  cunning  look.  His  disorientation  de- 
creased and  he  passed  good  nights.  He  would  answer 
questions  by  groaning.  He  would  say,  "  They  think  I  am 
a  Tartar."  The  end  of  the  mental  disorder  coincided  with 
the  cure  of  the  paratyphoid  fever.  According  to  Merklen, 
the  paratyphoid  bacillus  in  these  cases  serves  to  bring  out 
a  psychopathic  taint.  This  particular  patient  had  always 
been  of  a  sad  demeanor,  uncommunicative,  very  impression- 
able and  emotional.  Two  other  cases  had  always  been  some- 
what below  normal. 


SOMATOPSYCHOSES  1 73 


Diphtheria:  Post-diphtheritic  symptoms. 


Case  127.     (Marchand,  191 7.) 

A  farmer,  37,  was  evacuated  March  20,  1916,  for  diphtheria. 
April  I ,  paralysis  of  tongue  and  uvula,  impairment  of  vision. 
These  symptoms  rapidly  improved,  but  paralysis  of  the  legs 
appeared  and  then  of  the  arms.  This  paralysis  lasted  until 
he  was  sent  to  the  neurological  center  June  28  for  post-diph- 
theritic paralysis,  wherein  it  was  found  that  voluntary  move- 
ments of  the  legs  could  be  performed,  though  painfully  and 
of  slight  extent ,  that  walking  was  impossible,  that  there  was  a 
considerable  atrophy  of  legs  and  arms,  that  the  knee-jerks, 
Achilles  jerks  and  plantar  reflexes  were  absent.  There  was 
complaint  of  pains  in  the  legs  and  over  nerve  trunks. 

Improvement  followed,  the  atrophy  gradually  passed  away, 
and  the  voluntary  movements  of  the  legs  became  more  ex- 
tensive; but  by  October  the  reflexes  had  not  yet  reappeared. 
Yet  the  patient  had  begun  to  walk  on  crutches  and  soon  was 
able  to  get  on  with  canes  only.  The  improvement  did  not 
continue.  He  did  not  raise  his  heels  and  dragged  his  toes. 
There  was  now  a  clonic  tremor  of  the  legs  as  soon  as  the 
weight  of  the  body  was  put  on  them.  During  movements  of 
legs  carried  on  in  dorsal  decubitus  there  was  found  an  ir- 
regular tremor  of  the  legs  with  twisting  of  the  trunk.  The 
muscular  strength  was  well  preserved.  There  was  a  slight 
muscular  atrophy.  The  tendon  reflexes  had  now  come  back, 
though  the  right  Achilles  jerk  was  weak  and  the  plantar 
reflexes  were  absent.  There  was  a  hypalgesia  of  the  legs 
which  ceased  sharply  at  the  middle  of  the  thighs.  There 
was  a  slight  hypoacusia  on  the  left  side.  Visual  fields  nor- 
mal. The  patient  complained  of  feelings  in  the  inside  of  his 
bones.     Electrical  reactions  normal. 


174  SOMATOPSYCHOSES 

Diphtheria :  Hysterical  paraparesis. 


Case  128.     (Marchand,  191 7.) 

A  soldier,  24,  was  evacuated  June  24,  191 5,  from  Roussy 
for  diphtheria  and  was  treated  by  serum,  receiving  80  cc. 
in  8  injections.  A  few  days  later  there  was  a  paralysis  of 
the  uvula  with  regurgitation  of  liquids  from  the  nose;  but 
patient  was  able  to  go  on  convalescence  July  21.  A  few  days 
later,  however,  he  noticed  that  his  legs  were  weak.  Vertigo, 
vomiting  and  painful  walking  followed,  and  his  convalescence 
was  increased  a  month.  The  paralysis  got  progressively 
worse.  September  10,  he  went  by  automobile  to  Libourne 
where  he  stayed  two  months.  He  arrived  at  the  Neurological 
Center  at  Bordeaux  November  9  with  diagnosis  "  polyneuritis 
of  legs."  He  could  not  walk  and  could  hardly  flex  thighs  on 
pelvis  or  legs  on  thighs.  Voluntary  movements  of  extension 
and  flexion  of  feet  and  toes  were  limited.  There  was  neither 
atrophy,  pain  nor  reflex  disorder.  Both  legs  were  analgesic, 
as  was  also  the  abdomen  up  to  the  umbilicus.  There  was 
complaint  of  dorsolumbar  pains  and  of  stomach  trouble  and 
lack  of  appetite;  vomiting  after  meals  frequent,  pulse  120. 

January  3,  the  patient  was  able  to  lift  his  legs  a  few  centi- 
meters above  the  bed  but  not  together.  There  was  now  a 
slight  muscular  atrophy  especially  on  the  left  side.  Knee- 
jerks  lively,  analgesia  limited  to  legs,  no  vomiting,  pulse  rapid. 

The  patient  was  sent  to  a  hospital  In  the  country  May  8 
to  July  8.  He  was  now  much  better.  His  legs  were  able 
to  support  his  body  but  he  could  not  walk.  Slight  atrophy 
of  left  leg.  There  was  hypalgesia  now  in  the  feet  and  legs 
below  the  knee.  There  was  no  pain  on  pressure  over  the 
nerve  trunks.  The  electric  reactions  normal.  The  patient 
could  now  walk  on  crutches.  He  was  Invalided  on  the 
temporary  basis,  December  12,  1916. 

It  does  not  appear  that  in  this  case  the  hysterical  paralysis 
was  preceded  by  polyneuritis. 


SOMATOPSYCHOSES  1 75 

Malaria:  Amnesia. 


Case  129.     (De  Brun,  November,  191 7.) 

A  soldier  lost  all  memory  of  his  hospital  stay  in  Salonica  and 
the  voyage  home.  He  could  only  remember  a  little  about 
the  hospital  at  Bandol.  There  is  a  period  of  transition  to  full 
memory  in  malarial  cases  characterized  by  sure  memory, 
vague  on  certain  points,  alternating  with  phases  of  almost 
complete  amnesia.  The  soldier  in  question  had  very  inexact 
memories  of  the  Bandol  Hospital,  and  could  only  remem- 
ber about  his  fevers,  that  they  began  about  noon  and  ter- 
minated about  four  o'clock.  Twice  he  had  been  found  in  his 
shirt,  walking,  unconscious,  in  the  passageway  of  the  hospital. 
Having  obtained  leave  for  convalescence,  three  months  after 
his  memory  gap  began,  he  went  to  Paris,  and  probably  had 
attacks  at  home.  He  vaguely  remembered  afterward  being 
carried  by  automobile  to  the  Pasteur  Hospital,  December  i. 
There  he  remained  to  the  end  of  March,  19 17,  without 
preserving  anything  but  the  vaguest  memories  of  an  inter- 
mediary period  of  more  than  six  months.  The  memory  in 
these  malarial  cases  often  remains  permanently  altered  and 
there  may  even  be  a  retrograde  amnesia,  carrying  back  to 
facts  prior  to  the  gap  and  an  anterograde  amnesia  relative  to 
facts  after  the  main  gap. 

Thus,  there  is  in  the  febrile  period  a  retrograde  amnesia 
and  in  the  post-febrile  period  a  retrograde  or  anterograde 
amnesia.  One  group  of  subjects  are  severe  cerebral  cases, 
and  the  memory  gap  appears  to  run  back  to  a  period  of  true 
mental  confusion.  But  there  Is  another  group  of  patients  who 
preserve  throughout  the  febrile  period  an  absolute  con- 
sciousness of  all  acts,  and  yet  the  memory  gap  is  just  as  sharp 
and  definite  as  in  the  confusional  cases. 


176  SOMATOPSYCHOSES 


Malaria :  Korsakow  syndrome. 


Case  130.     (Carlill,  April,  1917.) 

A  stoker,  45,  was  admitted  to  the  Royal  Naval  Hospital, 
Haslar,  November  6,  191 6,  from  the  Fifteenth  General  Hos- 
pital in  Alexandria,  to  which  he  had  come  from  a  hospital 
in  Bombay  about  three  weeks  before.  At  Alexandria  he  was 
anemic  and  showed  an  edema  of  legs  which  had  been  present 
for  six  weeks.  Cylindruria;  no  albuminuria.  At  Haslar 
there  was  no  cylindruria  and  no  edema,  and  nothing  but 
weakness,  gouty  arthritis  of  left  wrist,  right  ear  and  left 
great  toe.  Red  cells  4,650,000,  leucocytes  10,000  (52  per 
cent  polymorphonuclear,  46  per  cent  lymphocytes).  He  was 
rather  dull  mentally.  December  loth,  Dr.  Fildes  found 
malarial  organisms  in  the  blood  on  the  occasion  of  a  hyper- 
pyrexia (104°).  Quinine  was  given.  December  14th,  he  was 
transferred  neurological.  According  to  the  patient's  own 
story,  he  was  born  June  10,  1868,  lived  in  Fulham,  had  a 
daughter  aged  12  years,  had  recently  seen  his  wife  at  the 
hospital:  all  this  seemed  plausible  enough. 

Later,  however,  he  said  that  the  year  was  1899,  that  King 
Edward  was  king,  that  the  war  was  between  England  and 
some  field  forces,  etc.  This  well-nourished,  pale,  simple- 
looking  stoker  spoke  quietly  and  politely;  told  about  in- 
termittent fever;  about  being  eight  years  on  the  active  list, 
becoming  a  reservist  and  being  called  up  for  the  war.  He 
read  intelligently,  could  do  sums,  but  did  not  know  the  name 
of  the  hospital  and  was  confused  about  the  war.  He  recog- 
nized that  his  memory  was  not  as  it  should  be;  constantly 
stroked  his  moustache  and  chin.  He  was  happy  and  con- 
tented. 

The  gait  was  normal,  systolic  blood  pressure  140  mm, ; 
no  evidence  of  alcoholism.  Blood,  January  15,  1917,  con- 
tained 5,050,000  reds,  10,300  leucocytes  (63  per  cent  poly- 
morphonuclear, 37  per  cent  lymphocytes).  There  was  a 
bilateral  absence  of  the  ankle- jerks,  repeatedly  -confirmed  at 
subsequent  examinations.  Wassermann  reaction  was  nega- 
tive.    Puncture  fluid  contained  no  cells. 


SOMATOPSYCHOSES  1 77 

Instead  of  living  at  Fulham,  this  stoker  lived  at  Ports- 
mouth, and  had  not  been  seen  by  his  wife  for  four  years.  He 
had  done  i8  years'  active  service  and  had  last  sent  his  wife  a 
letter  from  the  Sailors'  Home  at  Bombay,  November,  191 6. 
They  had  been  married  21  years.  He  caused  astonishment 
with  his  wife  and  friends  by  announcing  that  Lord  Roberts 
and  General  Buller  were  in  command  at  the  battle  of  the 
Falklands.  He  continued  to  say  that  he  lived  at  Fulham. 
He  was  discharged  home,  January  22.  It  seems  as  if  he 
were  living  through  the  period  of  the  Boer  war. 

Carlill  considers  that  alcoholism  may  be  ruled  out,  and 
there  is  no  likelihood  that  the  gout  was  the  cause  of  the 
neuritis.  He  believes  that  the  neuritis  was  probably  ma- 
larial. Possibly  the  illness  suffered  in  Bombay  may  have  been 
beriberi  or  it  may  have  been  malarial  nephritis. 


178  SOMATOPSYCHOSES 

A  complication  of  malaria. 


Case  131.     (Blin,  August,  1916.) 

A  Senegalese  corporal  of  machine  gunners,  21  (early  life 
normal  save  for  sore  throats  and  coughing),  was  a  robust, 
well-developed  man  of  75  kilos  when  he  entered  the  hospital 
at  Konakry,  February  15,  1916.  He  was  given  the  diagnosis: 
malarial  anterior  spinal  paralysis. 

It  seems  that  he  had  joined  a  Colonial  regiment,  April  8, 
191 5,  attended  classes  as  a  recruit,  left  Bordeaux  November 
I  for  Dakar,  arriving  there  November  11.  He  stayed  there 
some  sixteen  days,  during  which  time  he  slept  without  mos- 
quito-netting. November  16,  he  left  for  Konakry,  and  had 
his  first  febrile  symptoms  November  27,  with  vomiting, 
headache,  and  prostration.  His  temperature  ran  as  high  as 
41,  but  by  December  had  fallen  to  normal,  after  quinine. 

The  corporal  was  sent  away,  cured,  to  his  company  at 
Kouronesa,  December  6.  There  was  more  fever,  headache, 
and  vomiting  during  the  railway  trip.  Quinine  again  relieved 
the  fever,  but  a  bloody  diarrhoea  set  in  so  that  it  was  only 
at  the  end  of  January  that  he  could  go  on  service. 

February  6,  another  attack  of  fever,  with  shivering  and 
perspiration,  lasted  for  some  three  hours.  He  could  hardly 
stand  by  himself  and  had  to  be  helped  in  walking.  Next 
day,  another  spell  of  three  hours  of  fever;  definite  paralysis 
set  in,  affecting  both  legs.  February  8  the  arms  were  at- 
tacked by  paralysis  which,  unlike  that  of  the  legs,  was  a 
progressive  one,  attacking  first  the  shoulders,  then  the  elbows, 
the  wrists,  and  finally  the  hands.  All  the  body  muscles  were 
in  a  state  of  flaccid  paralysis,  as  well  as  the  muscles  of  the 
face.  The  patient  was  now  afebrile.  February  9  there  was 
a  slight  speech  defect;  the  tongue  was  slightly  paralyzed, 
and  swallowing  became  painful.  The  jaw  movements  re- 
mained normal.  The  muscles  of  the  face  were  intact  and 
the  patient  could  whistle,  move  his  lips,  and  move  his  eye- 
balls normally.  Vision  normal.  The  pupils  were  fixed  in 
dilatation,  more  widely  on  the  left  side.     There  was  a  slight 


SOMATOPSYCHOSES  1 79 

contracture  of  the  vesical  sphincter,  necessitating  the  cath- 
eter.    The  tendon  and  cutaneous  reflexes  were  lost. 

By  February  14,  when  the  patient  was  sent  to  the  Bellay 
Hospital,  muscular  atrophy  had  made  its  appearance.  No 
Plasmodia  could  now  be  found  in  the  blood,  which  showed 
71  per  cent  polynuclear  leukocytes,  20  per  cent  mononu- 
clears, 9  per  cent  lymphocytes. 

This  state  lasted  til  February  25.  Despite  the  fact  that 
the  patient  ate  well,  emaciation  rapidly  progressed.  The 
buttock  showed  a  very  few  signs  of  decubitus.  Upon  this 
date  there  was  pain  from  a  marked  orchitis  of  the  left  side, 
the  cause  for  which  remains  unknown  (no  history  of  gon- 
orrhoea; catheter  used  for  the  last  time,  February  15). 
The  temperature  which  attended  the  orchitis  came  down  in 
three  days;  the  patient's  appetite  was  singularly  good,  but 
the  muscular  atrophy  increased.  The  speech  defect  mean- 
time disappeared,  and  the  patient  swallowed  more  readily. 

March  7  a  slight  and  hardly  perceptible  movement  could 
be  noted  in  the  fingers  of  the  left  hand.  Two  days  later, 
similar  movements  appeared  in  the  right.  March  11  he 
could  spread  his  fingers  in  a  kind  of  creeping  movement. 
Next  day  slight  movements  were  possible  with  the  legs,  and 
March  13  the  knees  were  movable.  March  14  the  patient 
could  lift  his  head  from  the  pillow.  The  range  of  movement 
now  increased  all  over  the  body.  According  to  the  patient, 
those  parts  were  the  first  to  regain  power  that  had  been  at- 
tacked last.  This  certainly  seemed  to  be  the  case  with  re- 
spect to  the  left  upper  limb,  in  which  first  the  hand  and 
wrist,  then  the  elbow  and  shoulder,  successively  recovered 
power.  The  legs  regained  their  power  in  the  same  way 
proximad.  March  17  the  patient  could  sit  up  and  grasp 
objects  with  the  left  hand.  The  cremaster  and  plantar  re- 
flexes appeared,  — the  former,  more  on  the  right;  the  latter, 
more  on  the  left.  The  left  pupil  remained  in  wider  dilata- 
tion than  the  right. 

The  treatment  was  by  quinin  and  potassulm  lodid,  with 
massage.  The  patient  was  apparently  on  the  highroad  to 
complete  recovery,  and  left  for  France  March  21,  weighing 
63  kilos. 


1 80  SOMATOPSYCHOSES 


Trench-foot :  Acroparesthesia. 


Case  132.     (CoTTET,  September,  1917.) 

A  fantassin,  36,  carpenter  by  trade,  went  into  the  trenches 
October,  19 14,  and  had  two  attacks  of  trench-foot,  first  in 
January,  191 5,  when  there  was  a  painful  swelHng  of  the  foot 
and  secondly  in  July,  191 6,  when  there  were  some  bullae  on 
the  dorsal  aspect  of  the  feet.  These  were  not  serious  and 
the  fantassin  did  not  report  sick. 

He  was  wounded,  August  2"^,  1916,  by  shell  fragment  on  the 
right  elbow,  was  evacuated  to  the  ambulance  where  the 
fragment  was  extracted  and  then  to  a  hospital  which  he 
left  cured  with  a  seven  days'  leave.  Although  he  had  not 
suffered  in  any  way  from  his  feet  while  in  hospital,  and  had 
not  been  exposed  to  cold,  the  bullae  reappeared  on  the  feet 
just  as  they  had  been  in  July.  They  in  fact  now  formed  a 
sort  of  exanthem  occupying  symmetrically  the  dorsal  sur- 
faces of  the  toes.  The  bullae  contained  serum.  They  were 
confluent,  varying  from  pin  head  to  a  nut  in  size,  were  as  a  rule 
round,  but  sometimes  irregular.  The  eruption  went  on  to  a 
cure  rapidly  and  on  the  twelfth  day  the  bullae  had  dried  up. 
This  patient  had  hypesthesia  up  to  the  knees,  hypesthesia 
of  the  dorsal  surfaces  of  the  feet,  hyperesthesia  of  the  plantar 
surfaces  and  ankles,  hypesthesia  of  the  forearm  and  the 
elbow  and  of  the  dorsal  surfaces  of  the  hands  with  possibly 
exaggerated  sensibility  of  the  palma  surfaces.  Hypesthesia 
of  the  face  was  limited  to  a  small  part  of  the  right  ear. 
The  reflexes  were  normal  and  there  was  no  atrophy.  The 
name  "  paresthetic  trench  acrotrophodynia  "  was  given  to  it. 

In  a  service  of  eighty  beds  Cottet  found  within  two  months 
fifteen  instances  of  these  acroparesthetic  disorders  regarded 
as  neuritic  changes  in  trench-foot  of  a  latent  and  lasting 
character  which  would  have  remained  unobserved  unless 
there  were  disorders  of  sensibility.  In  fact  similar  disorders 
of  sensibility  may  be  found  without  any  history  of  gelure  des 
pieds,  forming  a  latent  type  of  neuritic  alteration  hardly 
noticed  by  the  patient  himself.  In  twenty-six  cases  Cottet 
found  sixteen  with  hypesthesia  of  the  ears  and  of  the  nose. 


SOMATOPSYCHOSES  l8l 


Bullet   injury  of  spine;    bronchopneumonia:    6tat 
crible  of  spinal  cord. 


Case  133.     (RoussY,  June,  1916.) 

As  to  the  development  of  eschars,  Roussy  reports  the 
case  of  a  lieutenant  wounded  September  25,  191 5.  There 
was  a  penetrating  wound  of  the  interscapular  region.  The 
bullet  had  entered  on  the  posterior  aspect  of  the  right  scapu- 
lar region  and  had  emerged  at  the  level  of  the  first  dorsal 
vertebra.  October  i,  a  neurological  examination  showed 
flaccid  paraplegia,  knee-jerks  normal,  Achilles  jerk  weak  on 
the  right,  plantar  reflexes  flexor,  cremasteric  reflex  absent  on 
the  right,  and  both  abdominal  reflexes  absent.  There  were 
pains  in  the  legs  and  arms.  There  was  retention  of  urine 
with  overflow.  A  slight  dulness  on  the  right;  temperature 
from  38  to  39  degrees. 

Four  weeks  later  the  knee-jerks  had  become  very  weak, 
and  the  Achilles  jerks  were  now  absent.  There  was  an  ex- 
tensive diffuse  atrophy  of  the  lower  leg  and  thigh  muscles, 
and  a  hypesthesia  of  pronounced  degree  had  developed 
throughout  the  legs,  over  the  buttocks,  and  in  the  lumbar 
region.  Anal  and  vesical  sphincters  relaxed;  dejections  volu- 
minous; sacral  decubitus  as  well  as  healed  eschars.  Decem- 
ber 5,  the  patient  was  transferred  to  the  Army  neurological 
center;  temperature  rose;  there  was  much  expectoration; 
paracentesis  yielded  no  fluid;  pneumococcus  in  the  sputum. 
Cystitis  had  developed  despite  extreme  care.  Extensive 
edema  of  the  legs  developed.  There  was  increased  dulness 
on  the  right  side,  coughing  and  dyspnea.  Death,  January 
17- 

The  autopsy  showed  a  bronchial  pneumonia  of  the  right 
lower  lobe,  confluent,  imitating  a  lobar  pneumonia.  The 
left  lung  also  showed  extensive  confluent  bronchopneumonia 
at  the  base  as  well  as  disseminated  areas  and  edema  of  the 
middle  and  apical  portions.  Infectious  splenitis,  large  fatty 
liver,  swollen  kidneys,  no  pyonephritls. 

The  spinous  processes  of  the  6th  and  7th  cervical  vertebrae 


1 82  SOMATOPSYCHOSES 

were  injured.  There  was  no  obvious  gross  disease  within 
the  theca  except  that  there  was  a  slight  adhesion  between 
the  dura  mater  and  the  anterior  surface  of  the  spinal  cord  at 
the  level  of  the  7th  cervical  and  highest  dorsal  vertebrae. 
There  was,  however,  a  depression  on  the  anterior  surface  of 
the  spinal  cord  at  a  lower  level,  namely,  at  the  level  of  the 
4th  dorsal  vertebra.  Microscopic  examination  showed  myelo- 
malacia with  small  cavities  in  the  1st  and  4th  dorsal  seg- 
ments, suggesting  the  etat  crihle. 

According  to  Roussy,  these  patients  Injured  in  the  spinal 
region  are  particularly  sensitive  to  cold  and  support  transfer 
badly  even  when  the  disease  is  short.  Such  patients  should 
be  evacuated  to  the  interior  after  the  shortest  delay  pos- 
sible. Sometimes  these  patients  show  rib  fractures;  these 
are  in  the  posterior  portions  of  the  ribs  and  are  due  to  the 
fall  of  the  man  when  struck.  It  might  be  possible  even  that 
the  spinal  lesions  should  through  the  action  of  the  sym- 
pathetic nervous  system  favor  lung  infection. 


SOMATOPSYCHOSES  1 83 


Shell-explosion :  Hystero-organic  symptoms ;  decu- 
bitus;  radicular  sensory  disorder. 


Case  134.     (Heitz,  May,  1915.) 

A  soldier,  32,  was  bowled  over  in  a  first-line  trench  by  the 
bursting  of  a  shell  that  he  did  not  see  coming,  September  14, 
1914.  He  regained  consciousness  only  in  the  middle  of  the 
night,  finding  himself  half  covered  with  water.  He  was 
taken  up  by  the  stretcher-bearers  at  eleven  in  the  morning. 
Paralysis  in  the  legs  was  then  absolute.  There  were  pains 
in  the  legs  and  in  the  back,  but  there  was  no  evident  lesion. 
Knee-jerks,  plantar  reflexes,  and  abdominal  reflexes  absent; 
cremasteric  reflex  absent  on  the  left,  weak  on  the  right. 
Tactile  sensations,  on  the  contrary,  were  almost  intact  ex- 
cept for  a  slight  diminution  over  the  feet  and  the  external 
aspects  of  the  lower  legs.  Sensitiveness  to  pin-prick,  how- 
ever, was  abolished  throughout  both  lower  extremities,  and 
diminished  in  the  abdomen  and  back  up  to  two  or  three 
centimeters  above  the  level  of  the  umbilicus;  that  is,  in- 
cluding the  territory  of  the  first  lumbar  and  the  last  three 
dorsal  roots.  Sensibility  to  heat  was  abolished  in  the  feet, 
the  external  aspect  of  the  lower  legs,  and  the  posterior  as- 
pect of  the  thighs,  but  was  preserved  in  the  second  and 
third  lumbar  territory,  in  the  anterior  aspect  of  the  thighs, 
as  well  as  in  the  region  below  the  umbilicus.  Micturition 
was  impossible.  Constipation  the  first  few  days  yielded 
spontaneously  September  20.  There  were  signs  in  the  bases 
of  both  lungs,  corresponding  with  a  suffocating  feeling.  Sep- 
tember 22,  he  was  evacuated,  almost  well,  without  signs 
of  pulmonary  congestion,  having  regained  the  power  of  urin- 
ation and  some  capacity  to  move  the  legs  sidewise.  Feb- 
ruary, 1915,  after  evacuation  to  a  hospital  at  Vic,  he  showed 
sacral  decubitus,  soon  reaching  the  size  of  a  hand,  as  well 
as  trochanteric  decubitus;  traces  of  albumin  in  the  urine, 
sacral  and  sciatic  pains  (recalcitrant  to  morphine). 

He  began  to  Improve  December  25.  Camphorated  oil 
and  the  sitting  posture  relieved  the  pulmonary  congestion; 


184  SOMATOPSYCHOSES 

the  temperature,  which  had  oscillated  round  38  degrees,  fell; 
the  decubitus  scarred  over;  the  knee-jerks  reappeared  to 
some  extent,  and  movements  began.  February  5,  the  patient 
had  become  able  to  walk  without  crutches.  There  was 
still  a  two-franc  sized  area  of  decubitus  over  the  sacrum,  and 
still  a  little  spinal  pain  in  w^alking. 

It  is  difficult  to  consider  this  case  only  functional  in  view 
of  the  decubitus,  to  say  nothing  of  the  radicular  distribution 
of  the  sensory  disorder.  Heitz  brings  this  and  the  previously 
given  case  (No.  i)  into  relation  with  Elliot's  case  of  tran- 
sient paraplegia  (see  Case  210)  and  Ravaut  (see  Case  201). 


SOMATOPSYCHOSES  1 85 


Shell-shock  (windage?) ;  typhoid  fever ;  ".neuritis  " 
actually  hysterical. 


Case  135.     (RoussY,  April,  191 5.) 

A  Colonial  soldier  was  sent  back  from  the  front,  Septem- 
ber 12,  1914,  for  nervous  disorder  due  to  the  shock  of  the 
windage  of  a  bullet.  He  had  not  lost  consciousness.  Under 
observation  at  his  station,  he  got  typhoid  fever,  and  was  cared 
for  at  Paris  from  the  beginning  of  October.  About  October 
15  he  began  to  feel  pains  in  his  left  shoulder,  neck,  and  arm. 
The  diagnosis,  neuritis,  was  made  and  was  strongly  borne  in 
upon  the  patient,  so  that  upon  the  cure  of  his  typhoid,  he 
went  out  on  two  months'  leave  with  a  complete  impotence 
and  much  pain  of  the  left  arm.  At  the  end  of  his  relief,  he 
was  evacuated  to  Villejuif.  January  24,  it  was  found  that 
he  had  no  somatic  phenomena  whatever,  despite  the  fact  that 
the  left  arm  and  a  part  of  the  forearm  was  powerless,  and  so 
painful  that  the  patient  cried  out  when  his  arm  was  moved. 
There  were  a  few  cracklings  in  the  scapulo-humeral  joint. 

Hot  air  and  reeducation  cured  the  man  in  less  than  two 
months  (March  20),  though  the  disorder  had  lasted  for  four 
months.  The  patient  had  been  retired  for  hysteria  before 
the  war  and  had  re-enlisted. 


1 86  SOMATOPSYCHOSES 


Bullet   wound   of   pleura:    Reflex  hemiplegia  and 
double  ulnar  syndrome. 


Case  136.  (Phocas  and  Gutmann,  May,  1915.) 
A  soldier,  26,  was  wounded  in  the  enfilading  of  an  Argonne 
trench  December  17,  1914.  He  felt  the  bullet  like  an  elec- 
trical shock,  and  fell.  He  had  been  leaning  forward  at  the 
time  and  suddenly  felt  the  left  half  of  his  body  go  paralyzed 
and  his  mouth  pulled  to  one  side.  He  did  not  lose  con- 
sciousness, and  spat  up  a  good  deal  of  blood  five  minutes  after 
falling.  He  lay  in  the  trench  all  night,  unable  to  move  his 
left  leg  except  by  the  aid  of  his  right.  He  was  evacuated  next 
day.  There  was  a  five-franc  piece  wound  at  the  upper  border 
of  the  left  scapula,  four  finger-breadths  from  the  median 
line.  There  were  a  few  lung  signs  which  rapidly  cleared  up. 
December  28,  the  hemiplegia  was  better,  although  neurologi- 
cal examination  showed  weakness  of  left  upper  extremity, 
abolition  of  deep  reflexes,  and  certain  skin  changes  of  the 
left  hand  with  edema  {main  succulent),  decreased  resistance 
of  muscles  of  lower  extremity  to  passive  motion,  especially 
of  adductors  and  flexors,  exaggerated  polykinetic  left  knee- 
jerk,  ankle  clonus,  Babinski  reflex,  abdominal  and  cremas- 
teric reflexes  absent  on  left,  platysma  paralysis  left,  with 
complete  paralysis  in  the  inferior  distribution  of  the  facialis; 
whistling  impossible.  Also  the  left  eye  could  not  be  closed 
singly.  Synergic  movements  of  the  lower  part  of  the  par- 
alyzed face  when  the  right  hand  of  the  patient  was  grasped. 
There  were  also  sensorimotor  disorders  in  the  ulnar  dis- 
tribution on  both  sides,  with  complete  anesthesia  to  pin 
prick.  There  was  also  an  area  of  hyperesthesia  of  the 
anterior  and  postero-intemal  aspect  of  the  right  forearm 
from  below  the  elbow  to  the  wrist.  The  tendon  reflexes 
were  weak  but  distinct  on  the  right  side.  The  left  arm  had 
feelings  of  pain,  with  elancements  and  formication  from  the 
shoulder  to  the  fingers  on  the  ulnar  distribution.  There  was, 
of  course,  also,  local  hyperesthesia  due  to  the  wound  of  the 
thorax. 


SOMATOPSYCHOSES  1 87 

Lumbar  puncture  showed  a  fluid  normal  in  all  respects. 
We  deal  with  a  hemiplegia  of  organic  nature,  associated  with 
the  bilateral  ulnar  syndrome.  The  hemiplegia  followed  the 
trauma  immediately.  When  the  ulnar  phenomena  appeared 
is  unknown. 

The  lung  complications  cleared.  The  pains  disappeared; 
motion  returned  up  to  the  level  of  the  facialis.  The  patient 
got  up  and  three  months  later  went  on  convalescence,  still 
presenting  Babinski,  exaggerated  knee-jerk  and  weak  arm 
reflexes  on  the  left  side.  The  bilateral  ulnar  syndrome  had 
disappeared  six  weeks  after  the  patient  entered  hospital. 
Phocas  and  Gutmann  cite  a  considerable  literature  on  nerve 
complications  of  pleural  trauma,  among  them  syncopes  of 
grave  prognosis;  a  relatively  frequent  pleural  epilepsy  (forty- 
five  per  cent  fatal)  or  epileptic  status  (seventy  per  cent 
fatal) ;  and  the  rare  hemiplegia.  Accidents  and  death  have 
followed  exploratory  puncture  of  the  pleura.  Air  embolism 
is  probably  not  the  cause.  Phocas  and  Gutmann  prefer 
the  theory  of  a  reflex  disorder  starting  from  the  pleura. 


SOMATOPSYCHOSES 


Hysterical  tachypnoea. 


Case  137.     (Gaillard,  December,  1915.) 

A  man,  23,  came  to  the  Lariboisiere  November  29,  191 5, 
in  a  hurr>'  to  show  evidence  that  he  had  been  invaUded  for 
valvular  lesion  of  the  heart.  In  point  of  fact,  the  interne 
found  a  murmur  at  the  base.  Yet  there  were  things  in  the 
military  papers  suggesting  caution.  The  patient  next  morn- 
ing showed  no  malaise,  dyspnoea,  or  any  evidence  of  serious 
disorder.  The  contractions  of  the  thorax  beat  in  time  with 
contractions  of  the  alae  of  the  nose,  about  112  per  minute. 
Here,  then,  was  a  cardiopulmonary  patient.  The  heart  im- 
pulse was  exaggerated;  the  patient  could  not  or  would  not 
stop  breathing  to  aid  the  auscultation,  but  almost  absolutely 
normal  sounds  could  be  heard  at  the  apex  and  the  base.  A 
valvular  lesion  could  be  excluded.  The  lungs  were  perfectly 
normal.  The  patient  was  requested  to  stop  his  gymnastics, 
which  might  have  succeeded  elsewhere  but  could  not  at  the 
Lariboisiere! 

How  could  the  man  have  established  the  synchronism  of 
pulse  and  respiration  and  synchronous  tachypnea  and  tachy- 
cardia? \\'hy  should  he  persist  in  this  form  of  sport,  since 
he  had  already  been  invalided?  The  family  history  was  not 
especially  suggestive  (father  albuminuric,  died  at  59 ;  mother 
well,  probably  tuberculous).  Scarlet  fever  at  eight;  occu- 
pation, toumeur.  After  four  months  of  service  there  was 
gastric  disorder  followed  by  typhoid  fever  (despite  vaccina- 
tion, according  to  the  patient) .  Convalescent  leave  at  Paris, 
during  which  leave  he  had  swollen  legs  and  albuminuria. 
May,  1915,  gastric  difficulty;  valvular  lesion  determined; 
examination;  invalided.  At  home,  a  variety  of  complaints, 
for  which  treatment  was  unsuccessful. 

During  further  examination  it  was  noted  that  in  ausculta- 
tion the  head  of  the  examiner  was  lifted,  as  if  there  were 
hypertrophy  of  the  heart  or  an  aortic  aneurysm.  The  syn- 
chronism was  less  exact  on  December  2;  112  beats  to  128 
respiration.     Was  this  man  a  simulator?     Had  he  become 


SOMATOPSYCHOSES  1 89 

the  victim  of  his  own  enterprise?  There  was  no  evidence  of 
simulation.  It  was  a  question  of  a  monosymptomatic  hy- 
steria. Gaillard  discontinued  the  manihre  forte  and  under- 
took a  softer  treatment,  but  the  manihre  forte  had  caused  the 
family  to  want  to  take  him  away.  Perhaps  they  feared  a 
too  efficacious  treatment.  He  then  escaped  observation. 
It  is  probable  that  the  tachypnoea  ceased  during  sleep.  It 
was  not  so  marked  after  the  medical  visit  was  over. 


I90  SOMATOPSYCHOSES 

Soldier's  heart. 


Case  138.     (Parkinson,  July,  1916.) 

A  corporal,  21,  who  had  been  a  miner  and  entirely  well  up 
to  enlistment  in  August,  1914,  went  to  France  in  1915.  In 
June,  came  shortness  of  breath  and  palpitation  on  exertion; 
later,  precordial  pain  (fifth  space,  between  nipple  and  median 
line)  and  giddiness  on  walking.  Like  all  cases  of  true  so- 
called  "soldier's  heart,"  this  soldier  had  no  physical  signs 
indicative  of  heart  disease,  yet  reported  sick  for  cardiac 
symptoms  on  exertion.  In  this  particular  case,  as  in  about 
half  of  forty  cases  reported  by  Parkinson,  there  had  been 
no  disability  in  civil  life. 

August,  1 91 5,  the  soldier  was  admitted  to  the  casualty 
clearing  station,  where  the  apex  beat  was  found  in  fifth 
intercostal  space  internal  to  the  left  nipple  line.  The  first 
sound  was  duplicated  in  all  areas.  The  second  sound  was 
duplicated,  though  not  loudly,  at  the  base.  After  nine 
months'  treatment,  this  man  went  back  to  light  duty  with 
slight  symptoms. 

According  to  Parkinson,  the  absence  of  abnormal  physical 
signs  in  the  heart  of  a  soldier  should  not  prevent  his  dis- 
charge from  the  army  if  under  training  or  on  active  service 
he  shows  breathlessness  and  precordial  pain  whenever  he 
undergoes  exertion  well  borne  by  his  fellows.  A  simple 
exertion  test,  such  as  climbing  25  to  50  steps,  reproduces  the 
symptoms  in  such  a  patient.  The  rate  of  the  heart  at  rest 
is  a  little  higher  than  that  of  normal  men,  though  the  in- 
crease on  exertion  is  greater.  Nevertheless,  it  has  been 
proved  that  the  increase  of  rate  on  exertion  bears  no  relation 
to  the  symptoms  elicited  and  is  therefore  without  value  in 
judging  the  functional  efficiency  of  the  heart. 


SOMATOPSYCHOSES  I9I 

Soldier's  heart  ? 


Case  139.     (Parkinson,  July,  1916.) 

A  sergeant,  36,  had  been  in  the  army  from  17  to  29,  but 
in  1908  he  had  acute  rheumatism  and  was  discharged  from 
the  army.  He  then  became  a  furnace  man  and  had  shortness 
of  breath  and  palpitation  on  severe  exertion  with  syncope 
three  times. 

He  re-enlisted  in  August,  1914,  and  had  an  attack  of  or- 
thopnea and  edema  after  exposure  at  a  review.  However, 
he  improved  and  went  to  France  in  May,  1915,  where  he 
again  had  symptoms;  namely,  precordial  pain  and  breath- 
lessness  on  severe  exertion.  One  day  while  carrying  tele- 
phone wire  under  fire,  the  sergeant  felt  a  sudden  pain  in  the 
region  of  the  apex  beat,  shooting  down  the  right  arm.  "I 
thought  I  was  shot."  He  fell  down,  very  short  of  breath. 
His  left  arm  remained  sore  and  weak.  Two  days  later  came 
a  similar  attack,  this  time  with  unconsciousness,  and  the  left 
arm  was  now  useless.  Two  days  later  he  was  admitted  to 
hospital,  where  slight  breathlessness  but  no  pain  and  no  en- 
largement of  cardiac  dulness  could  be  found.  No  further 
details  are  available  but  it  seems  clear  that  this  man  is  unfit 
for  duty.  According  to  Parkinson,  it  is  probable  that  the 
infection  indicates  the  presence  of  some  degree  of  myo- 
cardial disease. 


192  SOMATOPSYCHOSES 

Strain  and  shell-shock:    Acceleration  of  diabetes 
mellitus. 


Case  140.     (Karplus,  February,  1915.) 

An  infantryman,  aged  22,  previously  healthy  and  from  a 
healthy  family,  was  struck  by  a  shell  fragment  in  the  fore- 
head and  lay  for  several  hours  unconscious.  He  did  not 
vomit.  He  had  a  number  of  furuncles  on  his  body  and  his 
urine,  upon  examination,  showed  a  severe  diabetes  mellitus 
which  increased  despite  treatment.  Upon  an  attempt  to 
withdraw  carbohydrate,  the  sugar  suddenly  sank  from  six 
to  four  per  cent.  Acetone  at  the  same  time  increased.  An 
abrasion  had  been  noticed  by  the  patient  a  few  days  before 
the  shell  explosion  on  the  spot  rubbed  by  the  tornister.  The 
patient  said  that  since  his  accident  he  had  had  to  urinate 
every  night  several  times  and  was  often  very  thirsty,  neither 
of  which  tendencies  had  he  had  before.  A  month  before  he 
became  merod  he  had  had  an  injury  of  the  hand  produced  by 
a  shell  fragment.     He  had  undergone  tremendous  strain. 

The  chances  are  that  the  excitement  and  the  strain  had 
more  to  do  with  the  diabetes  mellitus  than  the  shell  explosion. 


SOMATOPSYCHOSES  193 

Dercum's  disease. 


Case  141.  (HoLLANDE  and  Marchand,  March,  191 7.) 
An  adjutant  in  a  chasseur  battalion  was  buried  by  a  shell 
explosion,  which  killed  his  lieutenant  beside  him,  January  5, 
1 91 5,  at  Hartmannsweilerkopf.  Hematuria  followed ;  ten  days 
later,  fever  with  anorexia,  and  the  appearance  of  two  or  three 
lipomata  on  the  anterior  surface  of  the  thighs.  Remaining 
at  his  post,  the  adjutant  took  part  in  an  attack,  March  5 ;  was 
evacuated  on  the  8th;  "lipomatosis  with  febrile  reactions." 
He  spent  eight  days  at  Bussang,  and  thence  went  to  the 
hospital  at  Pont-de-Claix.  Here  marked  albuminuria  was 
noted;  the  lipomata  increased  in  volume;  others  appeared 
in  the  arms.  The  patient  was  transferred  to  the  Des- 
Genettes,  where  the  diagnosis  nephritis  was  added  to  the 
previous  diagnosis,  and  a  milk  diet  was  prescribed.  Con- 
valescence of  five  months  was  proposed.  The  lipomata 
increased  in  volume  and  in  number.  The  patient  was  then 
hospitalized  at  Avenue  Berthelot,  placed  in  the  auxiliaries, 
and  stationed  eight  months  at  his  depot. 

When  he  was  observed  by  Hollande  and  Marchand,  four 
nut-sized  tumors  were  found  on  the  anterior  surface  of  the 
left  thigh;  two  smaller  tumors:  one  of  them  painful  to  pres- 
sure, lay  on  the  inner  aspect,  another  the  size  of  a  small  egg 
lay  in  the  right  thigh,  and  there  were  two  others  on  the  in- 
ternal aspect  and  two  on  the  external  aspect  of  the  thigh.  A 
nut-sized  tumor  was  found  on  the  inner  border  of  the  right 
forearm,  and  below  it  another  lenticular  tumor.  A  nut- 
sized  tumor  was  found  on  the  left  forearm  below  the  elbow 
on  the  internal  border.  Small  tumors  were  found  on  the 
buttocks.  There  were  no  tumors  below  the  knees,  in  the 
upper  arms,  or  on  the  thorax.  There  were  14  tumors  in  all. 
The  smaller  the  tumor  the  more  sensitive,  and  there  was 
more  pain  when  the  tumor  had  just  appeared  and  during 
the  first  days  of  its  growth.  There  was  no  spontaneous  pain; 
pain  only  upon  a  blow  or  pressure.  Diminished  knee-jerks, 
especially  the  right ;  no  other  neurological  disorder,  although 
the  patient  complained  of  often  having  something  before  his 


194  SOMATOPSYCHOSES 

eyes.  There  was  a  marked  diminution  in  the  memory. 
Heart  was  in  the  5th  space  on  the  nipple  line,  pulse  no; 
Wassermann  reaction  negative;  red  blood  cells,  3,520,000, 
white  cells,  6500;  albuminuria,  hematuria,  leucocytes,  and 
urethral  cells  in  the  urine.  The  temperature  had  now  be- 
come normal.  The  lateral  lobes  of  the  thyroid  were  slightly 
larger  than  normal,  but  not  painful.  Sella  turcica  was  un- 
changed upon  X-ray.  Exploratory  puncture  of  a  tumor 
showed  much  free  fat,  without  fatty  acid  crystals  and  with 
some  fat  cells.  The  cells  could  not  be  cultivated  in  test  tube. 
The  authors  believe  it  doubtful  whether  this  instance  of 
Dercum's  disease  is  related  with  the  shell  explosion. 


SOMATOPSYCHOSES  1 95 

Hyperthyroidism. 


Case  142.  (TOMBLESON,  September,  1917.) 
A  private,  22,  was  selected  by  Col.  Garrod  for  hypnotic 
treatment  by  Tombleson  from  among  the  hyperthyroid 
cases.  He  was  admitted  April  3,  191 6,  with  a  typical  hyper- 
thyroidism, with  manual  tremor,  enlarged  thyroid,  pulse 
120,  blood  pressure  136-40,  and  hemic  murmur.  Tombleson 
induced  deep  somnambulism  at  the  first  hypnotic  sitting 
and  suggested  an  increase  of  nerve  strength  and  steadiness. 
The  suggestions  under  somnambulism  were  repeated  for 
ten  days.  An  occasional  added  suggestion  was  given  as  to 
lessening  of  the  thyroid.  At  the  end  of  the  ten  days  the 
patient  declared  himself  quite  well. 

Eight  of  twenty  consecutive  functional  cases  treated  by 
hypnotism  by  Tombleson  were  cases  of  hyperthyroidism  and 
in  virtually  all  of  these  an  effect  like  the  above  was  registered. 


196  SOMATOPSYCHOSES 


Shell-shock;  thrown  against  wall,  stunned,  emo- 
tional: Paroxysmal  heart  crises  six  days  later, 
observed  for  two  months.  Neurasthenia?  Mild 
Graves'  disease? 


Case  143.     (Dejerine  and  Gascuel,  December,  1914.) 

An  infantryman,  29,  was  sent  to  auxiliary  hospital  No.  274, 
for  heart  trouble,  a  little  thin  but  looking  vigorous  enough 
(typhoid  fever  at  13  and  some  diseases  of  unknown  nature 
and  of  brief  duration  while  in  military  service). 

September  24,  a  large  calibre  German  shell  burst  and 
threw  him  against  a  wall,  producing  no  wound  or  contusion. 
He  was  momentarily  stunned,  emotionally  much  affected, 
and  noted  at  the  time  extreme  palpitation.  He  was  evacu- 
ated to  Paris  September  30,  six  days  after  the  shock.  His 
pulse  was  130-134,  regular,  and  the  heart  seemed  not  to  be 
anomalous  in  any  respect. 

But  there  were  paroxysmal  crises  in  which  the  pulse  rose  to 
1 80  and  in  which  the  patient  fell  into  a  state  of  great  anxiety. 
The  mouth  temperature  in  the  midst  of  such  crises  would 
always  rise  to  38°,  and  this  temperature  would  outlast  the 
rest  of  the  seizure.  The  man  was  mentally  depressed  and 
apparently  indifferent,  preoccupied  with  his  heart  and  his 
insomnia,  but  at  the  same  time  emotionally  easily  affected. 
In  short,  he  was  a  neurasthenic.  There  was  no  change  in 
mental  state,  tachycardia,  or  paroxysmal  seizures  In  two 
months,  except  that  he  gained  weight.  Walking  and  climb- 
ing stairs  produced  dyspnoea.  Urine  was  negative.  Ac- 
cording to  Dejerine,  such  a  case  should  be  treated  by  psycho- 
therapy. 

Alquier,  in  discussion,  called  attention  to  the  slight  but  dis- 
tinct tremor  In  this  case,  dermographia,  and  spells  of  perspira- 
tion. He  suggested  that  the  case  might  be  one  of  mild 
Graves'  disease. 


SOMATOPSYCHO  SES  1 9  7 


Hyperthyroidism,     three     months,     following     ten 
months'  service,  at  times  under  protracted  shell  fire. 


Case  144.     (RoTHACKER,  January,  1916.) 

A  man  in  ser\'ice  ten  months,  under  strong  excitement  and 
at  times  under  protracted  shell  fire,  complained  of  palpitation, 
insomnia,  dizziness,  and  dyspnoea.  Hospital  notes  showed 
that  the  left  lobe  of  the  thyroid  was  somewhat  enlarged. 
Before  the  war  his  neck  could  not  have  been  very  thick;  he 
had  serv^ed  his  year  out  without  difficulty.  His  mother  is 
said  to  have  suffered  at  one  time  from  thick  neck.  Accord- 
ing to  the  patient,  he  had  never  suffered  with  heart  trouble. 
Heart  not  enlarged;  blowing  first  sound  over  the  apex. 
Graefe,  Stellwag  and  ]\Iobius  signs  negative.  Heart  rapid, 
not  irregular;  pulse  strong.  There  was  fine  tremor  of  the 
hands,  as  well  as  a  tremor  of  the  tongue.  Knee-jerks  in- 
creased. 

The  patient  was  at  first  sleepless  and  excited,  but  after 
three  weeks  in  bed  the  heart  murmur  had  disappeared.  After 
three  months,  he  was  ordered  to  Ersatz  with  the  left  side  of 
the  neck  measuring  20  as  against  18  cm.  on  the  right.  There 
was  a  soft  pulsating  swelling  of  the  thyroid.  First  sound 
over  apex  still  impure;  heart  action  now  regular;  pulse  64; 
blood  pressure  120  Riva-Rocci;  after  test  exercises,  slight 
dyspnoea.  No  cyanosis.  The  outstretched  hands  were  no 
longer  very  tremulous.  The  knee-jerks  were  still  increased. 
The  man  had  begun  to  sleep  well.  His  neck  was  apparently 
much  diminished  in  girth. 

Here  then  was  a  case  of  Graves'  disease  of  acute  develop- 
ment, brought  out  by  ner\'ous  stress  and  excitement  as 
well  as  by  10  months  of  war  work  and  exposure  to  shell  fire, 
—  with  approximate  recovery  after  three  months  of  rest. 


198  SOMATOPSYCHOSES 

Graves'  disease,  forme  fruste. 


Case  145.  (Babonneix  and  Celos,  June,  1917.) 
A  farmer,  31,  entered  the  Rosendael  Hospital,  Jan.  25,  1917. 
He  had  been  two  years  in  active  service.  The  family  history 
was  negative  except  that  one  of  his  sisters  had  had  dyspepsia. 
The  patient  denied  venereal  disease  and  alcoholism  and  had 
always  been  well.  At  the  Battle  of  the  Marne  he  was  slightly 
wounded  in  the  left  knee.  January,  191 5,  he  was  exposed  to 
gas  bombs  and  explosive  shells.  He  was  several  days  in  the 
hospital  spitting,  or  perhaps  vomiting  blood  and  was  sent  on 
a  long  convalescence.  On  returning  to  the  front,  he  had  to 
be  sent  back  to  hospital  with  a  note,  "  not  fit  for  service, 
nervous  troubles  and  paroxysmal  tachycardia."  In  point 
of  view  he  now  showed  a  number  of  symptoms  suggestive  of 
Graves'  disease,  such  as  a  definite  exophthalmia  which,  ac- 
cording to  the  patient,  started  up  a  short  time  after  the  shock 
and  a  tachycardia  (i  10-120)  with  circulatory  excitement,  a 
tumultuous  heart,  neck  arteries  contracting,  almost  dancing 
in  their  contractions,  together  with  a  systolic  murmur  msixi- 
mal  in  the  pulmonary  area,  not  retaining,  variable,  —  in 
short,  suggestive  of  an  inorganic  murmur.  There  was  also 
a  generalized  rapid  tremor  and  a  variety  of  vasomotor  dis- 
orders, such  as  blushing  and  paling,  perspiration,  exaggerated 
reflexes,  emotionality,  logorrhea,  jactitation.  There  were 
also  digestive  troubles,  regurgitation  after  meals  and  the 
patient  had  become  thin  and  weak. 

There  was,  however,  no  swelling  of  the  thyroid  gland  nor 
any  eye  signs  other  than  the  exophthalmia.  In  short  this 
case  is  doubtless  one  of  the  forme  fruste  of  Graves'  disease.  It 
seems  to  show  that  Graves'  disease  may  have  a  traumatic 
origin. 


SOMATOPSYCHOSES  1 99 


Somatic     complication     in     a     shell-shock     hysteria 
(Trauma). 


Case  146.     (Oppenheim,  February,  1915.) 

Musketeer.  No  faulty  heredity,  but  was  always  somewhat 
nervous.  On  October  26,  a  shell  burst  one  meter  in  front 
of  him,  burying  him  under  the  anterior  wall  of  the  trench. 
He  was  dug  out  and  taken  to  the  field  hospital,  where  he 
remained  unconscious  until  the  next  morning.  On  October 
29,  he  was  taken  to  the  reserve  hospital.  Severe  pain  in  the 
head,  entire  scalp  tender  on  pressure,  especially  in  the  left 
frontal  region,  left  side  upper  lip  swollen,  bluish  and  dis- 
colored. Left  tenth  and  sixth  ribs  broken.  Fracture  of 
skull(?).  November  10,  at  eight  o'clock  at  night,  sudden 
attack  of  vomiting,  and  the  patient  was  found  in  a  faint  in 
the  water  closet.  Almost  complete  paralysis  of  speech  and 
all  of  the  four  extremities.  Consciousness  obscured;  no 
sensory  disturbances.  November  11,  severe  headache  and 
vertigo.  Speech  somewhat  more  intelligible.  Pulse,  60  to 
68.  "  Evidently  secondary  hemorrhage  in  the  brain."  No- 
vember 12,  to  Augusta  Hospital.  November  20,  admission  to 
nerve  hospital.  Typical  aphonia.  Limitation  of  motion  in 
all  four  extremities,  but  no  paralysis  —  anergy.  Reflexes 
normal.  Unable  to  stand  and  walk.  Sensibility  preserved. 
Under  suggestive  treatment,  curative  gymnastics,  as  well 
as  electrotherapeutics,  the  aphonia  and  abasia  disappeared 
in  a  few  days,  but  the  patient  continued  to  complain  of  head- 
ache and  insomnia.  December  16,  an  attack  of  nausea, 
headache,  vomiting,  loss  of  consciousness,  followed  by  epi- 
staxis,  marked  tachycardia.  January  4,  in  his  sleep  he  felt  a 
prick  in  his  left  upper  arm,  as  if  he  had  pushed  a  sewing 
needle  into  the  arm.  X-ray  examination  showed  a  needle 
in  the  arm.     This  was  extracted  under  local  anesthesia. 


VIII.*   SCHIZOPHRENOSES 
(DEMENTIA   PRAECOX   GROUP) 


The  Sister's  ear  boxed  for  blow  to  a  German  soldier's 
pride:  Diagnosis  PSYCHOPATHIC  CONSTITU- 
TION! A  true  psychosis  develops :  hate  of  Prussia 
and  the  Junkertum;  Diagnosis,  DEMENTIA 
PRAECOX!! 


Case  147.       (BONHOEFFER.) 

A  sick  soldier  in  a  military  hospital  kept  complaining  of 
being  waked  up  too  early,  and  of  poor  food.  His  reactions 
looked  like  the  irritable  weakness  of  a  psychopath.  One  day 
he  went  into  a  room  where  a  woman  was  being  examined, 
without  knocking.  When  ordered  out,  he  boxed  the  Sister's 
ear. 

He  said  himself,  on  transfer  to  the  psychiatric  clinic,  that 
he  had  always  been  quarrelsome  as  a  child  with  his  brothers 
and  sisters,  subject  to  fainting  spells,  and  poor  and  stubborn 
in  military  ser\' Ice,  —  all  of  which  seemed  to  clinch  the  diag- 
nosis of  psychopathic  constitution. 

But  he  seemed  to  show  a  decided  lack  of  autocrltlque. 
About  boxing  the  Sister's  ear  on  her  saying  "  Please  go  out," 
—  his  idea  was  that  he  could  not  let  a  thing  like  that  happen 
to  him,  —  a  German  soldier  and  a  patient!  Moreover,  "It 
should  not  be  thought  that  perhaps  I  had  a  love  affair  with 
her!  There  was  a  cynicism  about  her."  The  Sister  had  a 
strong  sex  Impulse,  he  could  see  that  by  her  nose:  she  was, 
so  to  speak,  "  hypochondriacal."  Both  In  speech  and  writ- 
ing he  used  stilted  phrases.  The  ego  at  last  swelled  to  the 
point  of  his  saying  that  he  was  an  inhabitant  of  the  World 
and  hated  Prussia  and  Prussian  Junkertum. 

Then  came  unmotivated  states  of  excitement,  with  pressure 
of  speech  and  motion,  and  eventually  negativism.  Accord- 
ingly, the  diagnosis  hebephrenia  finally  replaced  that  of 
psychopathic  constitution. 

*  VII.  Geriopsychoses  (senile-senescent  group}  not  repre- 
sented in  war  cases  (see  page). 


SCHIZOPHRENOSES  201 


Dementia  praecox,  arrested  as  spy. 


Case  148.     (Kastan,  January,  191 6.) 

A  German  private,  called  to  the  colors,  was  supposed  to 
take  his  civilian  clothes  to  the  post  office  along  with  his 
comrades  on  March  21,  191 5.  He  did  not  get  his  package 
ready  in  time  and  was  ordered  to  go  with  another  troop.  At 
an  opportune  moment,  he  left  the  barracks  with  the  package 
of  clothing.  When  later  arrested,  he  said  that  he  had  gone 
by  railroad  to  Dirschau;  then  he  had  visited  Berlin.  After 
this,  he  had  walked  to  Bromberg,  Schneidemiihl,  and  Lands- 
berg. 

At  last  he  had  ridden  back  to  Kiistrln.  At  Kiistrin  some 
children  told  a  railway  official  that  the  man  was  making 
drawings.  There  was  a  petroleum  tank  near  by.  Accord- 
ingly, he  was  arrested  as  a  possible  spy.  He  claimed  that 
he  was  not  a  soldier. 

In  the  clinic,  he  looked  dull  and  smiled  a  good  deal.  It 
seems  that,  before  being  called  to  the  colors,  he  had  been  very 
angry  with  his  wife  and  had  even  threatened  her.  He  now 
explained  this  anger  as  his  wife's  fault.  She  had  attacked 
him,  he  said.  He  said  that  he  sometimes  had  attacks  of 
weakness,  which  used  to  last  two  days  at  a  time,  but  they  had 
recently  lasted  for  a  shorter  time.  He  said  that  his  thoughts 
always  wanted  to  be  somewhere  else.  In  fact,  he  had  not 
performed  military  duty.  His  uniform  had  been  gotten  for 
him,  but  he  had  had  no  further  orders.  Sometimes  in  a  fever 
or  dream  his  head  seemed  to  be  as  big  as  a  room,  as  if  there 
were  no  space  for  it.  There  was  an  itching  in  his  legs,  he 
said,  which  often  fell  asleep  so  he  could  not  stand  on  them. 
He  had  had  syphilis  seven  years  before,  after  which  he  had 
been  hoarse,  forgetful,  and  anxious. 

Examination  showed  perceptive  power  and  knowledge  to  be 
good.  He  played  the  violin,  but  always  the  same  tunes. 
He  said  that  he  had  not  worked  in  Berlin  during  the  winter 
of  1 9 14.  He  spoke  as  if  he  had  been  in  another  sanitarium, 
where  he  did  nothing  but  dream  by  himself,  taking  no  in- 


202  SCHIZOPHRENOSES 

terest  in  things,  and  lying  indifferently,  with  a  blanket  over 
him. 

He  said  that  when  he  received  the  uniform  he  had  a  long- 
ing for  clean  underclothes.  Requested  to  explain  the  mean- 
ing of  the  uniform,  he  remarked:  "  Why,  many  have  these 
things  on." 

Re  dementia  praecox,  Lepine  states  that  in  the  French 
army  instances  of  dementia  praecox  have  been  numerous  in 
the  interior,  both  at  the  time  of  mobilization  and  at  the 
time  of  calling  out  sundry  new  classes.  He  notes  that  the 
courtmartial  and  invaliding  experts  have  neither  the  leisure 
nor  the  experience  necessary  to  keep  these  men  from  going 
into  the  army.  The  somewhat  frequent  remissions  in  de- 
mentia praecox  make  the  task  all  the  more  difficult.  To  be 
sure,  the  stuporous  and  catatonic  cases  are  not  very  much 
in  evidence  in  the  army;  when  such  cases  do  occur,  it  is  easy 
enough  to  evacuate  the  patients  to  a  hospital  for  observa- 
tion. Far  more  troublesome  are  cases  of  a  less  advanced  or 
milder  nature.  Here  are  cases  in  which  judgment  is  deficient, 
and  in  which  quite  unsystematic,  incoherent,  and  transient 
delusional  ideas  occur.  The  patient  looks  quite  normal  to 
the  non-psychiatric  expert.  Something  odd  happens  which 
quite  suddenly  reveals  the  delusional  ideas.  For  example, 
there  is  a  fugue,  or  else  the  soldier  goes  to  his  superior  and 
aggressively  chides  him  for  having  troubled  him  the  night 
before.  These  particular  psychopaths  are  among  the  most 
dangerous  to  be  found  in  the  army. 


SCHIZOPHRENOSES  203 

Fugue,  catatonic. 


Case  149.     (BoucHEROT,  1915-6.) 

A  gunner,  aged  23,  enlisted  on  the  expiration  of  his  regular 
period  of  service  and  was  a  good  soldier,  in  excellent  health, 
up  to  June,  1915.  He  then  began  to  have  a  few  vague  ideas 
of  persecution.  In  a  short  time  these  became  more  definite 
and  he  caused  talk  by  requesting  to  go  into  another  corps 
because  his  comrades  did  not  like  him.  He  told  his  brigadier 
that  the  soldiers  were  frightening  him  by  magnetism.  He  had 
hallucinations  of  hearing  people  say,  "  He  will  get  it."  He 
kept  by  himself,  would  not  eat  and  stood  motionless  for 
long  periods  of  time  before  his  mess-tin.  He  was  often  found 
in  a  dreamy  state  of  apathy.  One  day  he  left  the  cantonment 
without  leave,  wandered  through  fields,  had  coffee  in  a  village 
and  then  started  off  in  no  special  direction.  The  police 
took  him  without  resistance  the  next  day.  He  said,  "  My 
comrades  are  in  politics;  they  are  going  to  cheat  me."  He 
was  brought  to  Fismes  and  the  ambulance  surgeon  said 
that  he  found  he  did  not  know  what  he  was  about.  He  was 
amnestic  for  the  fugue,  explaining  that  he  went  because  he 
was  frightened.     It  was  hard  to  get  him  to  eat. 

July  14,  he  was  evacuated  to  Fleury  protesting  arrogantly, 
but  this  phase  of  excitement  passed  and  he  became  absolutely 
indifferent  and  disoriented.  He  became  untidy  in  his  person 
and  in  no  way  could  his  attention  be  attracted  whether  by 
mentioning  his  family  or  the  war.  He  sometimes  made  ape- 
like grimaces  and  sometimes  laughed  causelessly.  He  was 
occasionally  negativistic,  but  in  general  was  perfectly  com- 
pliant with  the  requirements  of  the  hospital.  Now  and  then 
he  started  off  impulsively  to  escape  but  was  brought  back 
quite  indifferent.  Now  and  then  he  went  into  bizarre  con- 
tortions on  a  medical  visit  or  aped  gestures  of  bystanders. 
He  began  then  to  go  into  stereotypical  attitudes.  This  case 
is  the  only  catatonic  one  found  by  Boucherot  in  his  war 
group. 


204  SCHIZOPHRENOSES 


Desertion:    Schizophrenic-looking    behavior.    Ad- 
judged responsible. 


Case  150.     (CoNSiGLio,  1915.) 

An  Italian  private  in  the  artillery,  a  telephone  operator 
at  the  front,  came  up  for  desertion  in  the  face  of  the  enemy. 
It  seems  that  he  had  often  left  his  post,  going  off  for  a  number 
of  hours  and  drinking.  At  last  he  lost  his  position  in  the 
battery,  went  off  and  got  drunk  again,  and  was  removed  to  a 
hospital  and  held  as  a  neurasthenic  and  psychopathic  pa- 
tient. At  the  territorial  hospital  he  was  regarded  as  a  melan- 
cholic. He  still  showed  signs  of  alcoholism,  was  hallucinated, 
did  a  number  of  peculiar  things,  was  impatient  of  medical 
examination,  and  was  given  a  furlough  of  two  months  for 
convalescence.  He  apparently  grew  somewhat  better  in 
his  father's  home,  but  went  to  a  physician  there  and  presented 
his  certificate  as  a  mental  case.  His  behavior  was  so 
peculiar  on  subsequent  arrest  that  he  was  sent  for  obser- 
vation to  Consiglio. 

It  appeared  that  he  had  been  in  military  service  from 
August,  19 1 2,  and  had  been  imprisoned  for  a  space  of  eight 
weeks  for  disobedience  when  he  had  been  in  military  service 
for  six  months.  He  had  been  punished  in  the  army  nine 
times,  once  being  given  70  days  for  lying.  He  was  regarded 
as  an  undisciplined  soldier  but  not  as  a  nervous  or  mental  case. 

At  hospital  he  was  in  a  semi-stupor,  claimed  that  he  was 
forgetful,  was  apathetic  concerning  home  and  relatives,  com- 
plained of  pain  in  the  head,  and  altogether  preserved  a 
strange  and  stolid  attitude  with  occasional  gestures,  mimicry, 
and  stereotyped  reactions.  As  he  had  come  to  be  operated 
upon,  he  looked  about  for  the  cannon  that  was  to  be  used  in 
the  operation.  Accordingly  the  question  of  dementia  praecox 
might  well  be  raised. 

His  Indifference  turned  out  actually  to  be  assumed  and 
pretentious.  He  preserved  throughout  an  arrogant  tone,  and 
there  were  features  in  his  voice  that  strongly  suggested  simu- 
lation. 


SCHIZOPHRENOSES  205 

According  to  Conslglio,  we  are  dealing  with  an  epileptic 
degenerate,  addicted  to  alcohol,  lying,  and  immorality.  The 
question  concerning  responsibility  was  settled  in  the  affirm- 
ative. Of  course,  it  might  be  thought  that  the  case  was 
one  of  pathological  intoxication,  in  which  case,  the  man  might 
be  regarded  as  only  semi-responsible.  However,  the  phenom- 
ena of  simulation,  not  merely  in  the  observation  hospital  but 
also  in  the  period  of  apparent  depression  and  strange  con- 
duct immediately  following  his  arrest  for  desertion,  led  to 
the  decision  that  the  man,  despite  his  nervous  abnormality, 
was  responsible  for  his  act.  He  was  condemned  to  20  years 
in  prison. 

Re  dementia  praecox,  Buscaino  and  Coppola  found  a  num- 
ber of  cases  of  dementia  praecox  amongst  soldiers  admitted 
to  hospital  during  the  period  of  mobilization;  cases  amongst 
men  who  had  not  yet  been  at  the  front.  These  mobilization 
cases,  in  fact,  were  as  a  rule  either  cases  of  dementia  praecox, 
cases  of  a  psychopathic  constitution,  or  cases  of  alcoholism. 


206  SCHIZOPHRENOSES 


A  disciplinary  case :  Schizophrenia,  alcoholism. 


Case  151.     (Kastan,  January,  1916.) 

In  October,  19 14,  a  German  soldier  returned  to  his  barracks 
late  from  a  drinking  bout.  He  insolently  called  for  order, 
brandishing  his  arms,  and  when  the  captain  rebuked  him,  he 
kept  a  cigar  in  his  mouth.  Examined  in  hospital  (Allenberg), 
he  was  very  reticent  at  first  but  wrote  his  name  up  over  the 
bed  with  the  additional  word  ''Dead.''  He  answered,  "  I 
don't  know  "  to  most  questions.  Although  it  was  December, 
he  said  the  season  was  summer.  He  was  to  be  shot  for 
disrespect,  he  said,  but  showed  more  disrespect  at  every 
remonstrance.  "  What  is  your  regiment?"  "  I  am  no  sol- 
dier at  all,  you  know.  I  have  already  been  discharged  as 
unfit  for  service."  "  Have  you  been  in  prison?"  "  I  don't 
know.  My  father  often  thrashed  me."  Then  suddenly, 
after  a  moment,  "  I  was  in  prison  five,  seven,  and  two  years, 
and  my  father  was  in  prison  four,  six,  and  three  years."  He 
said  that  he  had  drunk  ether  and  urged  the  physician  to  try  it, 
as  one  saw^  all  sorts  of  beautiful  pictures  and  figures  and  heard 
music. 

Upon  investigation,  it  was  found  that  the  man  had  been 
in  a  provincial  sanatorium  for  some  form  of  degenerative 
mental  disease  with  excitement.  He,  at  this  time,  had  given 
a  number  of  fantastic  stories  concerning  his  wanderings. 
For  example,  he  said  he  had  come  from  Australia,  where  he 
had  eaten  snipes  and  crows ;  that  he  was  on  his  way  home  and 
would  get  there  in  half  an  hour  (real  distance  10  hours). 
Or  again,  he  would  roll  his  eyes,  assume  a  false  name  and  say 
that  he  had  come  from  Morocco,  or  that  he  was  the  emperor 
and  would  not  play  soldier.  When  asked  to  repeat  digits,  he 
habitually  omitted  the  last  digit.  He  had  been  a  poor  scholar, 
and  of  a  tricky  and  treacherous  character. 

Despite  this  history,  he  had  behaved  well  In  the  army  at 
first,  though  insolent  to  superiors.  On  July  5  he  had  a  heavy 
drinking  bout,  and  wrote  next  day  to  his  mother  that  he  was 
going  to  commit  suicide.  At  this  time  he  had  Been  put  for 
safe  keeping  in  a  cell,  where  he  saw  foxes  making  as  if  to  bite 


SCHIZOPHRENOSES  207 

him.  He  also  said  that  he  was  a  rich  nobleman,  a  cavalry 
captain  with  a  servant  (asked  to  be  given  his  pressed  clothes 
and  his  cigarettes),  and  was  being  pursued.  He  rode  his 
pillow  as  if  it  were  his  horse,  and  hid  it  in  the  horse's  stable, 
namely,  the  bed.  He  ate  nothing,  as  he  thought  everything 
was  poisoned ;  smeared  himself  with  faeces  and  drank  urine 
as  "  strawberry  punch." 

We  are  evidently  here  dealing  with  a  psychopath  of  schizo- 
phrenic tendencies,  strongly  colored,  however,  by  alcoholism. 
The  patient's  father  was  a  drunkard,  and  a  brother  and 
sister  were  insane. 

Re  schizophrenia  in  the  German  army,  Saenger  remarks 
that  like  paresis,  so  also  latent  dementia  praecox  becomes 
acute  under  war  conditions.  E.  Meyer  states  that  amongst 
1 126  officers  admitted  to  his  hospital,  August  l,  1915,  there 
were  352  that  had  either  psychoses  or  neuroses,  amongst 
which  were  148  psychogenic  cases  (either  psychopathic  or 
hysterical),  128  with  what  he  terms  a  congenital  psycho- 
pathic diathesis,  and  76  with  traumatic  neuroses.  The 
cases  of  congenital  diathesis  were  somewhat  difficult  to  diag- 
nose, since  but  44  of  these  were  clearly  psychopathic  and  in 
the  remainder  the  question  of  dementia  praecox  or  of  cyclo- 
thymic conditions  arose. 

Stier  gives  statistics  for  1905  and  1906  in  the  German 
army,  namely  35  per  cent  of  dementia  praecox  cases.  Under 
war  conditions  the  army  has  developed  far  fewer  cases: 
Bonhoeffer,  7  per  cent;  Meyer,  7.5  per  cent;  Hahn,  13  per 
cent.  But  although  dementia  praecox  figures  so  much  less 
frequently  in  the  mobilized  army  than  in  the  army  of  peace 
times  (manic  depressive  psychosis  is  also  less  in  evidence 
under  war  conditions),  the  psychopathic  constitutions,  hys- 
terias, traumatic  neuroses,  and  the  like,  run  from  17.5  per 
cent  (Stier,  1 905-1 906)  to  54  per  cent  (Bonhoeffer),  37.5 
(Meyer),  43  per  cent  (Hahn). 


208  SCHIZOPHRENOSES 


Schizophrenic  symptoms.     Aggravation  by  service. 


Case  152.     (De  la  Motte,  August,  1915.) 

A  Landsturm  recruit,  20,  and  somewhat  peculiar  in  early 
life,  got  whipped  by  his  comrades  for  getting  back  too  late  from 
leave.  The  next  day  he  was  commanded  to  carry  a  machine 
gun.  He  threw  the  gun  down  and  made  for  the  barracks. 
He  was  put  under  psychiatric  observation,  as  he  said  he  did 
not  know  what  he  was  doing.  His  conduct  seemed  normal 
at  first  and  he  explained  that  he  had  heard  noises  and  sing- 
ing in  his  head,  — pointing  to  the  left  ear  where  there  was  an 
.otitis  media.  His  skill,  knowledge,  and  general  experience 
seemed  well  in  hand.  However,  he  was  not  very  communi- 
cative. Eventually  a  series  of  schizophrenic  symptoms  came 
to  light.  He  had  been  hearing  threatening  voices  of  varying 
intensity  for  two  years,  sometimes  a  veil  seemed  to  be  before 
his  eyes,  sometimes  he  heard  his  thoughts,  and  felt  that  his 
whole  personality  was  changing.  He  began  to  think  that 
his  facial  traits  were  gradually  turning  into  those  of  the 
physician.  The  hallucinations  were  so  insistent  that  some- 
times he  did  not  know  what  he  should  do.  He  was  evidently 
unfit  for  military  service,  and  the  decision  was  also  made 
that  the  mental  disease  had  been  aggravated  by  service. 

Re  schizophrenia  in  the  service,  most  authors  point  out 
that  there  was  either  patent  or  latent  schizophrenia  before 
mobilization.  E.  Meyer  attempted  to  make  a  study  of  the 
influence  of  the  war  on  psychopaths.  He  found  that  the 
ego  of  the  psychopath  remained  relatively  unaffected  by  the 
war.  Naturally,  the  paretics  and  the  seniles  were  unaffected. 
The  grandiosity  and  self-centredness  of  the  alcoholics  re- 
mained as  prominent  as  ever.  Seventeen  schizophrenic  cases 
were  studied,  and  some  of  these  yielded  entire  apathy  with 
respect  to  the  war;  others  had  the  content  of  their  delusions 
somewhat  affected.  Saaler  remarks  on  the  military  tinge 
which  dementia  praecox  assumes  under  war  conditions. 
Dementia  praecox  and  manic-depressive  psychosis  alike  show 
war  changes. 


SCHIZOPHRENOSES  209 

Shot  himself  in  hand.     Delusions. 


Case  153.     (Rouge,  191 5.) 

An  infantryman,  26,  left  for  the  front  August,  1914,  was 
slightly  wounded,  recovered,  went  back  to  the  front,  and  then 
is  said,  in  March,  1915,  to  have  shot  himself  in  the  hand. 
When  up  for  military  review  a  delusional  state  set  in.  It 
seems  that  he  had  been  interned  in  several  hospitals  for  ex- 
amination, but  escaped  four  or  five  times  because  physicians 
wanted  to  poison  him  and  had  partially  succeeded. 

He  came  to  the  Lemioux  Custodial  Institution,  July  12, 
191 5.  His  brother,  15,  was  a  voyou;  his  sister,  16,  was  an 
imbecile.  The  patient  told  about  his  military  history  and 
how  he  had  shot  himself  in  the  left  hand,  to  be  with  a  certain 
woman,  how  attempts  had  been  made  to  poison  him,  espe- 
cially a  certain  man  in  Bordeaux,  who  wanted  to  possess  the 
woman  in  the  case.  In  point  of  fact,  the  physicians  could 
not  save  him  from  this  enemy. 

The  patient  now  became  calm  and  indifferent,  lived  se- 
cluded and  almost  immobile.  In  November,  however,  he 
began  to  sit  down  and  eat  like  others,  making  low,  timorous 
answers,  vague  and  confused.  He  smiled  cheerfully  on 
questioning,  but  had  many  sad  ideas.  He  would  smilingly 
say  that  he  was  going  to  die  soon. 

Re  schizophrenia  in  the  French  army,  Boucherot  found 
eight  cases  amongst  107  soldiers  admitted  to  Loiret  in  the 
first  year  of  the  war.  He  remarks  upon  the  fact  that  the 
schizophrenic  cases  were  often  disciplinary.  The  group  is  a 
disciplinary  group.  Damaye  remarks  upon  the  difficulty  of 
diagnosis  betwixt  feeblemindedness  and  dementia  praecox 
as  observed  in  the  French  army. 


2 1 0  SCHIZOPHRENOSES 


Volunteer :  Dementia  praecox. 


Case  154.     (Haury,  1915.) 

N.  enlisted  voluntarily  for  three  years  in  the  Infantry, 
September  10,  19 12,  and  immediately  gave  indications  of 
abnormal  mentality  by  his  conduct.  He  made  mistakes  all 
day  long.  At  reveille  he  had  to  be  called  several  times,  and 
when  his  corporal  objected,  he  said,  "It  is  cold;  I  don't  see 
why  I  must  get  up;  I  am  free  to  remain  in  bed  until  8  o'clock." 
In  reply  to  his  corporal's  remonstrance  about  his  continued 
latenesses,  he  once  said,  "I  can't  get  ready;  I  have  no 
mirror  to  wash  before."  This  was  rather  surprising  conduct 
from  an  intelligent  printer-engraver,  who  had  lived  and  gone 
to  school  in  the  town  of  Lyons.  He  was  unable  to  make  his 
own  bed  or  to  perform  the  simplest  of  exercises  in  the  manual 
of  arms.  He  was  violent  on  several  occasions,  once  attack- 
ing a  comrade  who  had  given  him  an  order,  and  again  when 
another  had  taken  his  place  in  the  line.  His  reasoning 
faculties  were  those  of  a  young  child.  He  continued  doing 
these  strange  things,  and  was  finally  discharged. 

Re  dementia  praecox  amongst  American  troops,  Edgar 
King,  before  the  war,  concluded  that  some  5  to  8  per  cent 
of  the  American  cases  of  mental  disease  In  the  army  belonged 
to  the  paranoid  form  of  dementia  praecox.  King  lays  spe- 
cial emphasis  upon  dementia  praecox,  finding  that  more  than 
one-half  of  the  army  admissions  for  mental  disease  belong 
to  this  group.  He  calls  attention  to  the  number  of  deser- 
tions and  undesirables  in  the  group.  He  found  that  70 
per  cent  of  the  cases  showed  some  heredity. 


SCHIZOPHRENOSES  211 


Hysteria  versus  catatonia. 


Case  155.     (BoNHOEFFER,  1916.) 

A  reservist,  31,  was  in  the  hospital  about  Christmas,  19 14, 
for  rheumatism,  when  suddenly  he  became  excited  and  was 
sent  to  the  Charite  Psychiatric  Clinic.  He  was  restless  all 
night,  moving  about  in  bed,  grinding  his  teeth,  and  contin- 
ually getting  up.  He  had  a  blank  and  astonished  expression ; 
his  breathing  was  rapid  and  forced.  There  were  no  py- 
ramidal tract  symptoms,  but  muscular  power  was  dimin- 
ished, —  more  on  the  right  than  on  the  left.  While  the 
knee-jerks  were  being  tested,  the  legs  moved  (seemingly 
psychogenic).  Irregular  hypalgetic  zones  were  found,  and 
pain  was  less  well  felt  on  the  right  side  than  on  the  left. 
Answers  to  questions  on  mental  examination  were  made  with 
the  appearance  of  effort,  the  patient  breathing  deeply  and 
rapidly,  head  drooping,  forehead  wrinkling,  and  eyes  glanc- 
ing about  in  an  astonished  way.  "How  many  legs  has  a 
horse?  "  After  long  cogitation,  the  man  counted  slowly, 
—  I,  2,  3,  4.  "What's  your  wife's  name?"  "Marie  — 
Marie,  I  think." 

In  the  interpretation  of  this  case,  the  functional  paresis 
and  hypalgesia  of  the  right  side,  the  functional  pseudo- 
clonus  obtained  during  the  knee-jerk  test,  the  mental  situa- 
tion, —  rather  suggestive  of  a  hysterical  pseudodementia  or 
a  "Ganser  "  dazed  state,  —  make  the  probable  diagnosis  at 
first  sight  psychogenic.  Left  to  himself,  however,  the  pa- 
tient assumed  a  stereotyped  unchanging  posture;  he  would 
suddenly  cry  out,  without  particular  emotion,  that  he  was 
to  be  shot  or  executed;  there  was  a  tendency  to  rhythmic 
repetition  of  certain  answers  to  questions,  with  the  suggestion 
of  perseveration. 

After  a  time,  pronounced  rhythmic,  and  then  stereotyped, 
movements  started  in.  Suddenly  negativistic  phenomena, 
with  refusal  of  food  and  self-accusatory  ideas  set  in;  speech 
stopped  altogether.  Information  from  his  relatives  showed 
that  he  had  been  peculiar  for  some  time  and  had  for  years 
occasionally  said  that  he  was  going  to  be  shot. 


212  SCHIZOPHRENOSES 

Here  then,  instead  of  a  hysterical  pseudodementia,  was  a 
case  of  hebephrenia  or  perhaps  catatonia.  Possibly  there 
had  been  no  pseudodementia,  but  actually  an  elementary 
disorder  in  the  associative  process.  Possibly  the  defects 
which  the  patient  early  showed,  in  his  responses,  for  example, 
were  really  genuine  schizophrenic  blocking. 

According  to  Lewandowsky,  almost  all  cases  of  neuras- 
thenia, of  hysteria,  and  of  the  so-called  traumatic  neuroses, 
stand  out  very  clearly  as  functional.  Bonhoeffer  is  far  less 
certain  that  the  diagnosis  can  be  made  readily  in  all  cases. 
Antebellum  conditions  have  not  been  continued  in  war- 
time; hysteria  was  a  female  affair  antebellum,  but  under 
war  conditions,  it  is  found  necessary  to  draw  many  differ- 
ential diagnoses  in  the  male  betwixt  schizophrenics,  epilep- 
tics, and  psychotics,  on  the  one  hand,  and  hysterics  on  the 
other. 

Re  the  so-called  Ganser  symptom,  Hesnard  has  dealt  espe- 
cially with  the  value  of  what  he  calls  the  symptom  of  "ab- 
surd answers,"  finding  the  differential  diagnosis  between 
dementia  praecox  and  simulation  particularly  difficult. 
Hesnard  states  that  incoherence  is  very  hard  to  simulate. 
The  answers  of  the  Ganser  patient  are  not  always  incorrect, 
and  not  always  absurd.  The  patient  strikes  one  as  intact 
except  for  the  absurd  answers;  intimidation  and  other  ex- 
ternal conditions  affect  the  symptom  greatly.  Drugs  are 
refused  by  the  Ganser  patient. 


SCHIZOPHRENOSES  213 

*'  Hysteria  **  —  actually  dementia  praecox. 


Case  156.     (HovEN,  Henri,  191 7-) 

A  shell  burst  about  twenty-five  meters  away  from  a  soldier, 
21,  but  he  continued  in  the  military  service  thereafter  for  one 
month,  having  only  one  sympton,  a  trembling  of  the  arm. 
This  persisting,  he  was  evacuated  to  Calais,  then  to  Dury  to 
the  hospital  for  the  insane  where  he  stayed  six  months.  He 
was  transferred  from  Dury  to  the  Belgian  Hospital  for  the 
Insane  at  Chateaugiron  on  August  20,  191 5.  He  remem- 
bered nothing  of  his  stay  at  Dury,  Calais,  or  of  anything 
that  happened  after  the  shell-shock.  He  had  no  complaint 
and  wanted  to  go  back  to  the  front.  He  was  well  oriented 
for  time  and  space  and  had  no  disorders  of  association  or 
perception.  Besides  the  persistent,  retrograde  amnesia,  he 
showed  certain  neurological  disorders,  occasional  slight  ver- 
tigo, a  generalized  tremor  especially  affecting  the  arms  but 
disappearing  almost  completely  at  rest,  lively  tendon  re- 
flexes, intense  dermographia  and  cardiac  erethism.  Diag- 
nosis was  made  of  acute,  convulsional  psychosis  with  agita- 
tion, convalescent  phase. 

During  March  he  was  quiet  and  worked  about  the  hospital. 
In  April  the  patient  had  a  number  of  seizures  of  an  hysterical 
nature.  In  June  it  was  possible  to  evacuate  him  to  full  con- 
valescence. He  went  back  to  the  front  and  stayed  there,  but 
shortly  developed  catatonic  signs  with  visual  hallucinations 
and  delusions  of  persecution  of  a  non-systematized  nature, 
such  as  poisoning,  being  magnetized,  etc.  He  was  at  this 
time  poorly  oriented  for  time,  assumed  bizarre  and  theatrical 
attitudes,  showed  Ganser's  symptom,  was  oversuggestlble 
and  agitated  and  sleepless.  Diagnosis  of  dementia  praecox 
was  now  clear. 

Hoven  remarks  that  this  case  is  important  in  that  it  sug- 
gests that  a  diagnosis  of  hysteria  may  easily  be  mistaken. 


214  SCHIZOPHRENOSES 


Influence  of  war  experience  on  the  content  of  hal- 
lucinations and  delusions. 


Case  157.     (Gerver,  1915-) 

In  one  of  the  divisional  field  hospitals  Gerver  examined  a 
patient  with  a  very  vivid  paranoic  condition.  The  following 
were  some  of  his  hallucinations  and  delusions: 

The  patient  asserted  that  everyone  considered  him  a  spy. 
Voices  continually  told  him:  "You  are  a  spy."  "What? 
Spy?  Caught?  What?"  "You  will  be  shot  by  the  Ger- 
mans for  espionage."  About  three  months  before  his  present 
trouble,  the  patient  had  been  wounded  in  left  shoulder  by  a 
fragment  of  a  large  projectile.  The  wound  healed  and  ex- 
amination showed  a  big  scar  with  attachments  to  the  bone. 
The  patient  asserted  that  now  he  could  not  touch  anything 
with  his  left  hand,  as  there  immediately  go  from  it  "some 
currents  "  to  the  Germans  in  the  trenches  and  they  at  once 
begin  shooting  at  the  Russian  position.  Later,  the  patient 
could  not  even  look  in  the  direction  of  the  German  front, 
for  all  he  had  to  do  was  to  throw  a  glance  in  that  direction 
and  the  Germans  would  at  once  begin  a  bombardment. 

All  these  phenomena  he  explained  as  being  due  to  the  fact 
that  the  fragments  of  the  large  projectile  which  entered  his 
shoulder  were  poisoned  and  charmed.  Through  these  frag- 
ments there  went  currents  from  his  hands  to  the  Germans. 
The  patient  always  supported  his  left  hand  with  his  right, 
in  order  not  to  touch  anything  with  it.  He  slept  only  on  his 
right  side,  so  as  not  to  touch  the  bed  or  floor  with  his  left 
hand.  During  the  examination  and  conversation  the  patient 
tried  always  to  look  downwards,  so  as  not  to  throw  a  chance 
look  in  the  direction  of  the  German  front  and  call  out  their 
fire. 


SCHIZOPHRENOSES  2 1 5 


An  Iron  Cross  winner  had  a  hysterical-looking 
attack  (reminiscence  of  a  bayoneted  Gurkha). 
Later  he  begins  to  talk  of  **  this  damned  war  that  is 
so  vulgar"  and  of  ** atrocities,  concrete  and  ab- 
stract " :  Shortly  the  diagnosis,  hebephrenia,  had 
to  be  made. 


Case  158.     (BoNHOEFFER,  1915.) 

An  Iron  Cross  winner,  21,  in  the  field  from  August,  1914, 
to  the  middle  of  March,  1915,  at  first  in  France,  later  in 
Russia,  finally  went  to  hospital  for  rheumatism  and  sciatica. 
Three  months  later  he  had  to  be  transferred  to  the  Charite 
in  a  state  of  delirious  excitement. 

The  attack  began  suddenly.  He  thought  he  was  in  the 
field  telephoning  with  his  captain,  trembled,  threatened  to 
injure  people  about  him,  said  he  could  not  hold  the  position 
with  the  few  men  he  had,  and  the  like.  Next  day  he  quieted 
down  and  became  oriented  for  time  and  place.  He  explained 
that  he  had  seen  a  Gurkha  coming  upon  him  with  a  mallet, 
by  way  of  revenge  upon  him  because  he  had  stuck  his  bay- 
onet in  the  Gurkha's  breast.  Behind  a  little  hill  he  had 
seen  Frenchmen  and  Englishmen,  from  which  he  drew  the 
conclusion  there  was  going  to  be  an  attack  that  night.  A 
little  cloud  of  dust  he  thought  was  enemy  cavalry.  In  point 
of  fact,  he  said  he  had  once  on  patrol  stuck  a  Gurkha  through 
and  the  Gurkha's  eyes  had  since  followed  him  in  his  mind. 
He  had  seen  him  crawling  along  the  ground  one  evening  and 
heard  his  step.  The  patient  had  imperfect  insight  into 
these  hallucinations  when  questioned  about  them  during  the 
daytime,  and  still  talked  somewhat  as  if  the  experience  was  a 
real  one. 

At  first  the  situation  seemed  probably  one  of  hysterical 
delusion,  for  which  the  Gurkha  experience  served  as  material. 
In  point  of  fact,  further  observation  in  the  clinic  showed  that 
the  diagnosis  of  hysteria  was  wrong.  He  was  induced  to 
write  out  his  experience  in  a  style  quite  like  his  conversation; 
and  there  was  a  queer  tendency  in  his  writing  to  the  use  of 


2l6  SCHIZOPHRENOSES 

foreign  words,  somewhat  improperly  used.  After  a  time  he 
began  to  sit  about  dully  and  at  times  to  run  about  and 
throw  himself  into  and  out  of  bed,  or  strike  rhythmically 
with  his  shoes  on  the  floor,  or  draw  his  shoulders  together, 
making  grimaces,  rolling  his  eyes  and  breathing  deeply.  He 
said  he  had  to  make  these  movements  involuntarily  if  he 
were  in  some  way  excited.  But  the  peculiar  conduct  also 
often  occurred  without  any  emotional  prod.  His  emotions 
were  variable,  but  on  the  whole  indifferent  and  not  always 
quite  suitable. 

He  frequently  said  he  wanted  to  get  Into  the  field  again, 
giving  vent  to  superficial  phrases,  such  as  "atrocities,  con- 
crete and  abstract,"  and  "this  damned  war  that  is  so  vulgar." 
Yet  a  few  minutes  later  he  would  say  he  wanted  to  go  to  war 
at  Amsterdam  as  Amsterdam  had  pleased  him  very  much. 
He  said  he  now  had  a  good  many  thoughts  and  ideas  which 
formerly  he  had  not  had.  He  had  not  been  promoted,  he 
said,  because  he  had  once  angered  an  officer  in  another  com- 
pany. 

His  field  hospital  history  told  of  certain  oddities,  such  as 
his  lying  stiffly  in  bed  heedless  of  what  was  going  on  about 
him,  falling  into  causeless  depression,  failing  to  sleep,  and 
wandering  about. 

As  to  previous  life,  only  his  own  data  were  available. 
He  had  been  a  moderate  scholar,  had  been  rather  irritable 
and  thought  a  peculiar  character.  In  the  ward,  he  showed 
baseless  antipathy  to  certain  patients  and  said  they  were 
well.  He  seemed  to  have  no  insight  into  his  condition, 
yet  wrote  in  a  letter  that  the  insane  state  in  which  he  was 
had  very  much  "  augmented  his  mental  organism."  The 
diagnosis  of  early  hebephrenic  disorder  could  now  be  con- 
sidered established. 


SCHIZOPHRENOSES  21/ 


Occipital   trauma.     Mystical  visual   hallucinations 
and  explanatory  delusions. 


Case  159.     (Claude,  Lhermitte,  Vigouroux,  1917.) 

A  soldier,  33,  single,  was  wounded  in  the  right  occipital 
region  by  a  shell  burst  September  25,  19 15.  There  was  no 
sign  of  focal  lesion,  but  a  trephining  operation  was  done, 
which  healed  perfectly.  No  disturbance  of  vision  ensued. 
The  soldier  was  sent  to  convalesce  two  months  after  having 
been  examined  by  P.  ]\Iarie  at  the  Salpetriere.  He  went 
back  to  his  regimental  station  and  was  put  into  the  auxiliary 
service  April  26,  1916. 

In  the  early  days  of  September,  that  is  to  say,  a  year  after 
his  injury,  he  had  a  vision.  Above  the  church  cross  at 
Chantenay,  where  he  then  was,  he  saw  a  rainbow-colored 
bird,  passing  slowly  in  the  sky.  He  lowered  his  eyes  and  the 
apparition  followed  and  was  projected  on  the  white  walls 
around  him.  After  some  time  it  disappeared.  The  soldier 
himself  wondered  whether  his  brain  injury  might  not  have 
something  to  do  with  the  vision,  but  none  of  his  comrades 
wounded  in  the  head  had  had  any  such  vision.  So  then  he 
thought  of  tobacco,  of  which  he  was  a  moderate  user,  and 
stopped  smoking,  but  the  vision  returned  in  the  same  in- 
tensity four  months  later.  On  examining  the  bird's  face 
carefully,  he  found  that  it  was  the  Holy  Virgin's.  In  dreams 
he  also  had  analogous  visions  and  in  the  dreams  the  Holy 
Virgin  spoke  to  him,  but  what  she  said  he  did  not 
remember.  The  bird's  head  did  not  speak  to  him.  The 
soldier  was  now  convinced  that  it  really  was  the  Holy  Virgin 
who  had  visited  him  in  the  form  of  a  bird.  He  remembered 
that  he  had  asked  Notre  Dame  de  Lourdes  to  protect  him  on 
the  day  when  he  was  injured.  He  had,  in  fact,  eaten  a  bit 
of  cheese  that  day  upon  which  he  had  inscribed  a  prayer  to 
the  Holy  Virgin. 

Sometimes  he  saw  a  red  globe  shining  like  a  church  lamp; 
sometimes  white  or  black  ladies  descending  from  the  sky; 
sometimes  other  visions.     Now  the  Holy  Virgin  was  to  direct 


21 8  SCHIZOPHRENOSES 

all  the  soldier's  life,  but  why  should  he  be  specially  favored? 
Was  he  not  to  be  called  sooner  or  later  to  hold  a  high  rank? 
He  confessed,  in  fact,  that  he  was  to  be  the  King  of  France, 
and,  like  Joan  of  Arc,  was  to  save  his  country.  Now  the 
soldier  began  to  understand  the  hidden  significance  of  his 
surroundings.  Everything  around  him  was  symbolic,  thus, 
white,  of  purity,  order  and  royalty;  red,  of  anarchy,  disorder 
and  atheism.  Some  white  ship  which  he  saw  outstripping 
some  darker  ship  showed  him  how  the  kingdom  of  France 
was  arriving  once  more.  In  fact,  there  was  a  symbolism  in 
the  whites  and  yolks  of  eggs,  and  the  proportion  of  yolk  to 
white  was  as  one  to  five.  He  made  talismans  to  exorcise 
bad  spirits. 

Were  there  auditory  hallucinations?  If  so,  they  were  only 
episodic  and  took  no  part  in  either  the  construction  or  the 
fixation  of  the  man's  delusional  system.     Thus,  a  voice  once 

said  to  him,  "  All  is  not  lost.     You  will  be ."     May  25, 

1917,  he  entered  the  neurological  center  at  Bourges. 

As  to  the  interpretation  of  this  case,  it  seems  that  the 
patient's  mother  had  crises  of  depression  which  at  one  time 
caused  her  to  be  interned  in  the  Charite.  The  contributors 
of  this  case  do  not  believe  that  there  can  be  any  causal  link 
set  up  between  the  mystical  delusions  and  the  brain  injury. 

As  an  auxiliary  the  soldier  has  a  right  to  twenty  per  cent 
compensation  for  his  head  wound  with  loss  of  substance 
without  bulging  of  the  dura  mater.  Of  course,  as  an  insane 
person  he  must  be  retired.  The  aggravating  or  accelerating 
part  played  by  fatigue,  emotion  and  cranial  trauma  must, 
from  the  standpoint  of  compensation,  be  taken  into  account. 


SCHIZOPHRENOSES  2tg 

Shell-shock  dementia  praecox. 


Case  1 60.     (Weygandt,  191 5.) 

A  subaltern  who  had  been  in  the  service  since  1909  was  on 
patrol  under  shell  fire  from  the  enemy,  but  shortly  thereafter 
came  with  his  detachment  into  the  zone  of  the  German  fire. 
Six  men,  two  steps  away  from  him,  were  killed  by  a  shell. 
The  ofhcer  remained  stationary  with  the  rest  of  his  detach- 
ment until  darkness  set  in,  then  returned,  made  his  report 
in  due  order,  but  thereafter  tremors  set  in  over  his  whole 
body  and  he  lost  consciousness.  He  was  carried  to  the 
hospital  and  on  the  way  met  his  best  friend  whom  he  did  not 
recognize.  Arrived  at  the  hospital  he  was  unable  to  give 
answers  to  questions  or  obey  requests  for  two  or  three  hours. 
He  thought  he  was  hearing  calls,  commands  and  a  dull 
drohnen.  If  an  automobile  passed  he  was  frightened  and 
cried,  "Auto!  Auto!"  He  remained  subject  to  inhibition, 
anxiety  and  insomnia  for  a  long  time;  pulse  accelerated; 
visual  fields  somewhat  contracted  for  red.  Face  asymmetri- 
cally innervated  and  dermatographia.  Sent  to  the  reserve 
hospital,  he  was  still  apprehensive,  especially  at  night,  but  in 
the  course  of  a  few  days  became  perfectly  tranquil.  Only 
if  he  took  part  in  the  singing  of  war  songs  did  he  feel  transient 
sensations  in  his  knees. 

Here  is  a  case  of  psychic  shock  with  many  traits,  such  as 
inhibition  and  hallucinations,  suggestive  of  dementia  praecox. 
The  Abderhalden  reactions  (cortex,  white  matter,  testes, 
not  thyroid)  all,  according  to  Weygandt,  are  suggestive  also 
of  dementia  praecox. 


220  SCHIZOPHRENOSES 


Shell-shock  dementia  praecox. 


Case  i6i.     (Dupuoy,  1916.) 

A  machine  gunner,  23,  was  the  sole  survivor,  March  18, 
1 91 5,  of  the  explosion  of  a  large  calibre  shell  in  a  block  house 
containing  ten  men.  He  worked  himself  out  of  the  debris 
and  came  to  Dupuoy's  attention  in  September,  when  an  ex- 
tension of  leave  was  asked  for  him. 

There  were  two  groups  of  symptoms;  persistent  head- 
ache, painful  hyperacousia,  vertigo,  tremulous  walk,  cervical 
spinal  column  stiff  and  painful  both  spontaneously  and  to 
pressure,  muscular  weakness,  tremor  of  hands,  hypesthesia 
of  extremities  especially  upper,  exaggeration  of  tendon  and 
bone  reflexes  with  tendency  to  ankle  clonus  and  patellar 
clonus,  stemo  sign  lively,  frequent  nosebleeds  (two  to  four 
times  a  week),  profound  sweating,  unequal  pupils. 

On  the  mental  side  it  was  clear  that  the  man's  character  had 
changed,  according  to  information  supplied  by  the  mother. 
Aprosexia,  impairment  of  memory,  recollective  and  reten- 
tive, inability  to  give  age,  birth  date  and  similar  data.  Words 
came  with  difficulty.  Some  disorder  of  comprehension; 
stereotyped  replies;  negativism;  indifference;  he  would  sit 
hours  in  a  chair  or  on  a  bed  silent  and  inactive.  Fixed 
attitudes;  dull  glance;  eyelids  half  closed.  In  short,  it 
seemed  as  if  this  patient  was  a  case  of  catatonic  dementia 
praecox. 

Re  dementia  praecox  and  shell-shock,  Stansfield  remarks 
upon  the  similarity  of  certain  symptoms  found  in  Shell- 
shock  to  those  of  dementia  praecox;  for  example,  apathy, 
retardation,  amnesia  and  speech  defect.  According  to  Stans- 
field, one  often  gets  the  impression  in  a  Shell-shock  case  as 
though  the  trench  and  shell  fire  stress  had  merely  brought 
out  a  latent  dementia  praecox. 

Re  his  new  "stemo"  sign  (sternomastoid  contraction  on 
percussion  of  neck  at  level  of  third  dorsal  vertebra),  Dupouy 
claims  it  negative  in  normal  subjects,  positive  in  concussion, 
meningitis,  and  general  paresis. 


SCHIZOPHRENOSES  221 


Shell-shock ;  fatigue ;  fugue ;  delusions.    Recovery. 


Case  162.     (Rouge,  1915.) 

A  sergeant,  40,  had  had  nineteen  years  of  service  and  had 
been  married  five  months  when  he  was  recalled  to  the  colors 
when  war  broke  out,  and  sent  to  the  front.  March,  1915, 
he  was  exposed  to  bomb  explosions  during  a  very  intense 
bombardment.  He  then  got  into  the  way  of  saying  that  he 
was  akin  to  everybody.  April  20,  he  was  evacuated  on  the 
score  of  general  fatigue,  rejoined  the  company  May  17,  left 
his  comrades  at  the  end  of  June,  and  was  taken  up  as  a 
deserter  by  the  police,  who,  observing  his  state,  brought  him 
to  a  hospital.  He  there  showed  "  cerebral  overexcitement  " 
with  "  incoherence  and  nervousness."  In  two  or  three  days 
he  was  much  better.  He  was  evacuated  on  the  sixth  day  to 
the  hospital  at  Vichy. 

There  was  amnesia  for  the  fugue  and  he  could  remember  no 
further  back  than  the  extraction  of  a  tooth  at  the  Vichy 
hospital.  In  fact,  he  attributed  the  fugue  to  this  dental 
operation.  His  wife  took  him  home,  but  he  soon  threatened 
her  with  a  revolver ;  got  better  in  the  night  and  next  day  went 
about  apparently  normal,  buying  things,  however,  extrava- 
gantly. His  delusional  state  began  once  more,  and  two  days 
later  he  was  brought  to  Limoux.  It  seems  that,  while  in 
Mauretania,  he  had  formerly  shown  signs  of  mental  disorder, 
having  a  mania  for  wireless  and  airplane  inventions  and  the 
like.  A  cousin-german  had  also  been  in  a  hospital  for  the 
insane  twice,  recovering  each  time.  There  was  a  lingual  and 
manual  tremor.  The  man  had  not  been  recently  alcoholic. 
He  was  a  little  irritable  and  showed  a  little  megalomania, 
but  worked  hard  and  made  himself  useful.  He  went  out, 
recovered,  November  12,  191 5. 

Analysis  indicated  that  this  sergeant  received  a  moral 
shock  as  a  consequence  of  his  fatigue  and  the  shell  fire,  which 
emerged  in  a  spell  of  confusion.  It  may  be  that  his  pre- 
disposition had  something  to  do  also  with  this  spell  and  the 
fatigue.  In  any  event,  it  seems  as  if  the  latter  phenomena 
were  not  all  assignable  to  war  stress. 


IX.     CYCLOTHYMOSES 
(THE  MANIC-DEPRESSIVE  GROUP) 


A  maniacal  volunteer. 


Case  163.     (BoucHEROT,  191 5-6.) 

An  Alsatian  became  the  object  of  much  attention  when  he 
enlisted  at  the  outbreak  of  the  war  in  the  infantry  at  the  age 
of  59.  He  was  interviewed  and  soon  became  more  than 
naturally  exuberant.  The  peculiar  things  he  did  soon  brought 
him  to  Fleury  in  a  gay  and  expansive  mood,  singing  and 
talking  as  hail  fellow  with  everyone  he  met. 

The  next  day  he  grew  more  excited,  disrobed  and  threw  his 
things  out  of  the  window,  filled  his  bed  with  excrement  and 
wanted  to  smear  the  orderly  therewith.  He  took  other 
attendants  for  old  friends  and  wanted  to  kiss  them.  His 
language  and  ideas  were  incoherent.     He  broke  glass. 

This  situation  of  alternate  joy  and  anger  lasted  one  month, 
leaving  him  in  an  excitable,  unruly  state.  He  wrote  many 
prolix  letters  to  the  prefects  and  the  ministers,  insisting  on 
the  discharge  of  certain  patients  and  offering  plans  for  the 
defense  of  France.  He  got  better  and  finally,  in  October, 
1914,  was  invalided  home  still  slightly  exalted. 

Re  the  cyclothymias,  Montembault  remarks  that  manias 
have  been  less  numerous  than  melancholias  in  the  present 
war,  whereas  in  1870,  manias  were  more  common  than  mel- 
ancholias. Morselli  likewise  remarks  upon  the  rarity  of 
manias  amongst  the  Italian  soldiers.  Butenko  reports  upon 
the  maniacal  cases  amongst  the  Russians  and  how  the  men 
wish  to  enter  the  ranks,  the  women  the  nurse  corps.  E. 
Meyer,  for  Germany,  found  4  per  cent  manic-depressives. 
Birnbaum  quotes  from  Bonhoeffer  (3  per  cent)  and  Hahn 
(2  per  cent)  for  war  times  as  against  Stier's  9.5  per  cent  of 
cyclothymic  cases  in  the  antebellum  period,  1905-1906 

223 


CYCLOTHYMOSES  223 


Fugue:  melancholia. 


Case  164.     (LoGRE,  1916.) 

Logre  classifies  as  a  melancholic  fugue  the  adventures  of  a 
man  who  had  been  depressed  for  some  days,  had  stopped 
talking  and  eating,  and  ran  away  suddenly  in  the  middle  of 
an  attack  of  anxious  agitation.  He  was  very  anxious  over 
the  health  of  his  daughter,  whom  he  thought  to  be  severely 
ill.  It  was,  in  fact,  to  go  to  Paimpol  that  he  deserted,  but  he 
deserted  with  his  arms  and  without  any  money.  He  went  off 
on  foot  "in  the  Brittany  direction."  He  had  gone  50  kilo- 
meters, the  next  day,  and  was  picked  up  near  Chateau- 
Thierry  by  two  gendarmes,  who  fell  upon  him,  seeing  his 
regalia,  and  cried,  "Give  yourself  up!"  He  replied  in  a  firm 
voice,  "No,  I  shall  not  give  myself  up!"  and  seizing  his  gun 
he  made  at  one  of  the  gendarmes.  There  was  a  fight.  The 
gendarme  declared  in  his  report  that  he  judged  it  opportune 
to  retreat  behind  a  tree.  The  soldier,  knowing  his  trench 
lore  very  well,  barricaded  himself  behind  a  pile  of  beets. 
There  he  would  have  held  the  gendarmes  in  check  for  some 
time  if  another  had  not  succeeded  by  a  detour  through  some 
woods,  in  catching  him.  He  gave  himself  up  after  firing 
several  ineffective  shots,  but  not  without  getting  a  bullet  in 
his  left  thigh  himself.  With  the  charge  of  desertion  and 
attempt  to  murder,  he  was  handed  over  for  mental  exam- 
ination. He  was,  in  fact,  a  melancholic  patient,  subject  to 
attacks  of  anxiety,  and  requiring  long  observation  at  a 
neuropsychiatric  center  for  diagnosis. 

Chavigny  observed  numerous  victims  of  melancholia  char- 
acterized by  war  terror.  He  remarks  a  somewhat  curious 
fact  that,  whereas  the  melancholies  were  numerous  and  their 
mental  states  related  to  the  war,  on  the  other  hand,  the 
paretics  were  rather  apt  to  be  maniacal  than  melancholic. 
Soukhanoff,  however,  remarks  on  the  occurrence  of  depres- 
sion in  a  great  number  of  types  of  psychosis,  as  was  found 
in  the  Russo-Japanese  war.  Soukhanofif  found  frequent  in- 
stances of  schizophrenia,  wherein  the  melancholia  tends  to 
conceal  the  actual  dementia  praecox.  Soukhanoff  predicted 
that  depression  will  figure  largely  in  the  war. 


224  CYCLOTHYMOSES 

Apples  in  No-Man's-Land. 


Case  165.     (Weygandt,  1915-) 

A  soldier  in  November,  1914,  suddenly  climbed  out  of  the 
trench  and  began  to  pick  apples  from  an  apple-tree  between 
the  firing  lines.  The  idea  was  to  get  a  bag  of  apples  for  his 
comrades,  but  he  began  to  pelt  the  French  trenches  with 
apples.  He  was  called  back  and  on  account  of  his  strange 
conduct  sent  to  hospital.  Here  he  was  at  times  given  to 
pressure  of  speech  and  restlessness ;  he  would  climb  the  posts 
of  the  sleeping  room  and  then  loudly  declare  he  wanted  to 
get  back  to  the  trenches ;  he  did  not  want  to  go  back  to  Ger- 
many alive;  did  not  want  to  live  over  to-morrow;  was  guilty 
of  a  sin;  had  a  spot  of  sin,  Schand,  on  his  heart.  Sometimes 
he  refused  food  and  said  anything  else  tasted  better.  It 
seemed  he  had  formerly  talked  about  the  Iron  Cross. 

After  being  transported  to  Germany,  he  was  at  first  a 
little  negativistic  and  apparently  blocked.  He  talked  about 
his  experiences  and  said  he  wanted  to  go  to  Russia.  He  ex- 
plained the  episode  of  the  apples  on  the  basis  that  they  were 
all  really  hungry  and  that  he  had  sought  to  encourage  his 
comrades  who  were  unused  to  war.  He  had  noticed  the 
French  all  shot  too  high. 

Physically  there  was  a  somewhat  uneven  innervation  of 
the  face,  unilateral  epicanthus  and  an  areflexia  of  pharynx. 
Now  and  then  the  man  was  very  irritable,  but  in  general  he 
was  in  an  elevated  frame  of  mind. 

Weygandt  interprets  this  case  as  one  of  hypomania,  re- 
marking that  war  influences  may  serve  to  bring  out  preex- 
isting manic  depressive  tendencies. 

Re  differential  development  of  mania  and  depression,  see 
remarks  under  Cases  163  (Boucherot)  and  164  (Logre). 


CYCLOTHYMOSES  225 


Four  montiis  in  trenches :    Depression;  war  hallu- 
cinations, arteriosclerosis  (aged  38). 


Case  166.     (Gerver,  1915-) 

A  Russian  reservast,  a  private,  38,  went  into  the  trenches, 
March,  191 5.  Without  taking  part  in  any  battles  or  sus- 
taining any  injury,  he  four  months  later  became  depressed 
and  had  to  be  evacuated  to  a  hospital  and  thence  to  the 
interior,  little  changed  for  the  better. 

He  was  an  ill-nourished  man,  of  middle  height,  with  pallid 
skin  and  membranes;  arteries  sclerotic;  face,  eyelids,  and 
tongue  finely  tremulous;  hands  tremulous;  slight  dermato- 
graphia;  exaggerated  tendon  reflexes;  pulse  100. 

He  seemed  disoriented  for  time  and  place;  looked  weary; 
walked  wnth  back  bent  over;  spoke  in  whispers,  and  ap- 
peared somewhat  unclear.     Thinking  was  slow  and  difficult. 

He  occasionally  shuddered  and  looked  to  one  side,  said  he 
was  afraid,  and  was  constantly  troubled  by  thoughts  of  fire. 
The  Germans  were  pursuing  him;  he  could  hear  their  voices 
and  footsteps.  He  himself  was  doomed,  and  his  family  also; 
he  felt  he  was  the  cause  of  all  the  domestic  woe.  His  own 
heart  was  dying  away;  he  had  fits  of  anguish  and  causeless 
fear,  and  was  under  the  constant  expectation  of  death. 

One  day,  he  escaped  from  the  hospital  and  went  to  the 
chief  physician's  tent,  where  he  lay  on  the  ground.  When 
he  was  found  and  asked  why  he  was  there,  he  begged  the 
physician  to  save  him  from  the  Germans.  The  man  was  not 
alcoholic  and  had  no  previous  history  of  mental  disease. 

Re  early  arteriosclerosis,  Maltland  in  the  second  Interim 
report  of  the  British  Association  Committee  on  Fatigue  In 
Warfare,  speaks  of  the  many  Serbians,  who,  after  six  years 
of  nearly  continuous  Balkan  war,  show  a  marked  arterio- 
sclerosis. Maltland  remarks  that  the  line  officers  were  al- 
ready showing  (191 6)  a  growing  delicacy  of  perception  as 
to  the  "breaking  point."  Men  that  do  not  break  may 
return  from  the  lines,  pale,  with  low  blood  pressure,  and  a 
faiblesse  irritable,  shown  by  restlessness  of  hands  and  feet. 


226  CYCLOTHYMOSES 


War  stress :  Manic-depressive  psychosis. 


Case  167.     (DuMESNiL,  191 5-6.) 

A  naval  officer,  22,  transferred  from  sea  service,  went  into 
Belgium,  November,  1914,  in  a  Fusilleur  brigade  of  marines 
and  there  greatly  distinguished  himself,  growing  very  weary 
and  enervated,  however,  about  the  middle  of  April,  191 5. 
His  attitude  to  the  men  altered :  he  sometimes  struck  them ; 
gently,  though,  according  to  his  account.  They  must  do 
in  ten  seconds  what  they  really  could  not  do  under  ten 
minutes.  The  officer,  in  fact,  had  lost  all  notion  of  time. 
He  went  about  agitatedly,  contradicted  his  superior  officers 
and  was  troubled  because,  as  he  said,  they  often  were  men  of 
inexperience  as  compared  to  himself.  He  grew  irritated,  too, 
because  there  were  Free  Masons  in  the  army  and  when  he 
was  sent  to  the  asylum  in  July,  1915,  said  it  was  the  doing  of 
the  Free  Masons.  He  did  not  seem  to  have  any  hallucina- 
tions. His  ideas  and  sentiments  were  very  labile,  and  a  bit 
confused,  and  not  all  his  interpretations  dealt  with  Free 
Masons  and  occultism.  August  5,  however,  the  phase  of 
calmness  was  again  followed  by  agitation;  he  broke  things 
and  laughed  explosively.  August  10,  another  attack  occurred, 
with  destructiveness.  During  the  next  few  days  there  were 
alternate  phases  of  depression  and  excitation.  He  was  nega- 
tivistic,  resistive  and  struck  attendants. 

Re  war  stress  and  psychoses,  Morselli  finds  the  acute  cases 
on  psychopathic  soil.  First  in  the  list,  he  places  the  neu- 
rasthenias and  psychasthenias,  and  second,  the  hysterias, 
two  groups  which,  more  than  the  remainder,  may  be  said  to 
constitute  the  so-called  Shell-shock  group.  Third,  he  found 
depressions  ranging  over  into  a  delusional  state  with  suicidal 
ideas;  fourth,  a  species  of  stupor,  occasionally  catatonic, 
recalling  dementia  praecox;  fifth,  transient  hallucinatory 
states;  sixth,  confusions  (Meynert's  amentia?);  last,  manias. 

The  above  case  of  Dumesnil  appears  to  be  a  pure  case  of 
manic-depressive  psychosis  developing  on  the  war  basis,  but 
perhaps  merely  comes  from  a  latent  cyclothymia. 


CYCLOTHYMOSES  22/ 

Predisposition;  war  stress:  Melancholia. 


Case  i68.     (Dumesnil,  191 5-6.) 

A  farmer,  30,  was  mobilized  August  2,  1914,  and  was 
wounded  in  the  hand  September  27.  He  went  back  to  his 
depot  in  December  and  stayed  there  until  March,  191 5,  when 
he  was  sent  to  Dunkirk.  Before  leaving  the  depot  he  said 
that  he  had  heard  soldiers  declaring  that  he  was  not  doing 
his  duty,  that  he  was  going  to  be  court-martialed,  that  life 
was  at  an  end  for  him.  At  Dunkirk  he  said  these  same  sol- 
diers continued  to  say  the  same  things  about  him,  forming 
a  band  about  him,  led  off  by  a  subaltern  officer  who  meant 
to  frighten  him  and  to  make  him  talk.  One  night  sulphur 
was  thrown  at  him  for  poisoning  purposes;  he  complained  of 
this  to  a  sergeant  and  declared  he  did  not  understand  why 
he  should  be  thus  pursued.  After  the  bombardment  of  Dun- 
kirk the  hallucinations  grew  more  intense.  He  was  sent  to 
hospital  and  was  so  harried  by  the  voices  that  he  wanted  to 
throw  himself  down  a  staircase  but  was  caught  in  time. 
At  the  hospital  for  the  insane  he  complained  that  his  thoughts 
were  being  heard  and  loudly  repeated ;  he  was  made  to  make 
incoordinate  movements ;  was  treated  as  a  spy.  He  thought 
he  must  be  a  German  or  they  would  not  treat  him  so.  He 
waited  for  death  as  he  wanted  to  be  executed  at  once. 

This  man's  father  was  alcoholic.  He  himself  at  the  age 
of  fourteen  had  had  a  period  of  neurasthenia  with  some  sort 
of  nervous  seizure  for  a  period  of  five  months.  At  28  he  had 
a  rheumatic  seizure  which  kept  him  in  bed  fifty  days.  A 
daughter  bom  to  his  wife  had  died  a  few  days  after  birth. 

Dumesnil's  analysis  is  melancholia  with  delusions  of  per- 
secution, due  to  war  stress  in  a  predisposed  person. 

Re  melancholia  and  the  war  stress,  see  remarks  under 
Case  167.  Re  manic-depressive  psychosis  in  the  Russians, 
Khoroshko  found  9.4  per  cent  of  manic-depressive  cases, 
the  same  percentage  of  epilepsies,  10  per  cent  of  paretics, 
and  20.4  per  cent  of  schizophrenic  cases  amongst  a  group  of 
318  neuro-psychiatric  cases.  Almost  all  his  manic-depressive 
cases  had  been  patently  so  antebellum. 


228  CYCLOTHYMOSES 


Depression;  low  blood  pressure.     Pituitrin. 


Case  169.     (Green,  1917.) 

A  private,  22,  was  sent  back  from  Germany  as  insane.  He 
had  been  in  the  asylum  at  Giessen  seven  months,  and  a 
prisoner  in  all  fifteen  months. 

August  16,  1916,  he  was  admitted  to  Mott's  wards  at 
Maudsley  in  a  markedly  depressed  and  lethargic  condition. 
He  had  improved  somewhat  In  October,  but  still  had  periods 
of  depression.  He  was  put  on  thyroid  extract  (Green's 
treatment  was  in  doses  measuring  from  gr.  j  to  gr.  i,  t.d.s. ; 
according  to  Green,  the  effect  of  thyroid  extract  is  more 
rapid  when  coupled  with  pituitrin).  In  December  he  was 
given  pituitrin  extract  gr.  2,  t.d.s.  In  January,  1917,  he  was 
no  longer  depressed  or  lethargic.  He  complained  of  pain  in 
his  back,  found  to  be  due  to  a  bullet.     This  was  removed. 

Re  prisoners,  Imboden  found  amongst  20,000  French  sol- 
diers taken  prisoner  at  Verdun  after  the  severest  drum  fire 
and  strain,  only  five  neurotic  cases  (data  of  Morchen),  and 
Wilmanns  found  but  five  neurotic  cases  amongst  80,000 
prisoners.  Lust  reviewed  20,000  war  prisoners  in  Germany 
and  found  singularly  few  instances  of  neurosis.  Shunkoff 
notes,  however,  that  there  are  a  number  of  psychotic  cases 
amongst  the  prisoners  because  the  mentally  diseased  who  do 
not  disturb  the  military  routine  are  kept  in  the  line.  Bon- 
hoefifer  found  amongst  Serbians  taken  prisoners  by  Germany, 
emaciation,  atrophy,  heart  disease,  and  frequently  tuber- 
culosis. (See  Case  166.)  Bonhoeffer  noted  the  absence  of 
psychoses  amongst  these  Serbians,  drawing  the  general  con- 
clusion that  campaign  stress  was  unable  to  bring  out  psy- 
choses. But,  although  the  exhaustion  psychoses  are  not 
found,  there  are  exhaustion  neuroses  or  states  of  acute  ner- 
vous exhaustion,  characterized  by  somnolence  and  depres- 
sion, followed  by  a  mild  degree  of  overemotionality.  vum 
Busch  states  that  interned  German  civilians  have  gone  into 
psychosis  frequently.  It  is  said  that  one  in  10,000  war 
prisoners  in  Germany  has  committed  suicide.  Bishop  Bury 
found  at  Ruhleben  60  or  70  cases  of  psychosis. 


X.     PSYCHONEUROSES' 


Hallucination  in  the  field  (surprise  by  BOCHES) ; 
scalp  wound :  Three  psychopathic  phases  —  (a) 
over-emotionality,  {h)  obsessions,  (c)  loss  of  feeling 
of  reality  (victim  a  '*  constitutional  intimiste  "). 


Case  170.    (Laignel-Lavastine  and  Courbon,  July,  1917.) 

A  cashier,  31  (of  rather  weak  constitution  but  without 
hereditary  or  acquired  mental  taint  —  a  religious  man  and 
for  religious  reasons  chaste,  always  given  to  metaphysical 
speculation  and  introspection,  but  on  the  other  hand,  much 
interested  in  sports  and  very  sympathetic  with  English 
manners),  was  about  to  go  to  live  in  the  country  on  the  ad- 
vice of  his  physician  when  the  war  broke  out.  He  was 
called  to  the  colors  and  shortly  lost  his  tendency  to  bron- 
chitis, put  on  flesh,  and  felt  delighted  with  his  situation. 

After  almost  two  years  of  effective  service,  June  2,  191 6, 
when  his  troop  was  cautiously  advancing  into  a  trench  at  the 
end  of  which  they  might  be  taken  by  surprise,  suddenly  the 
officer  cried,  "  Saiive  qui  pent !  The  Boches  are  on  us ! "  The 
patient  remembered  seeing  Germans  emerge  from  every  side, 
remembered  his  fear,  how  he  had  turned  about  and  crossed 
over  a  palisade,  and  then  no  more  until  he  found  a  scalp 
wound  being  staunched  by  his  comrades  in  the  trench.  He 
put  on  his  own  dressing  and  followed  his  comrades  on  foot. 

He  quickly  got  well  of  his  scalp-wound  but  remained  in 
hospital,  very  weak,  extremely  impressionable,  jumping  at 
every  noise.  He  got  somewhat  better  with  the  rest  in  bed, 
though  even  a  month  after  his  hallucination,  he  had  a  spell 
of  insomnia,  thinking  about  his  future  and  the  possibility  of 
a  relapse,  and  having  war  dreams  from  which  he  would  awake 
in  a  sweat.  Once  on  awaking,  he  distinctly  heard  a  voice 
saying,  ''Well,  Charles?''  This  hallucination  occurred  five 
times,  under  exactly  the  same  circumstances,  except  that  once 
it  was  in  the   daylight.     Adrenalin   was  given,   i :  1000,   10 

229 


230  PSYCHONEUROSES 

drops  the  first  day,  20  the  second,  30  the  third,  and  a  like 
amount  on  the  following  days.  After  three  days  of  such 
treatment,  the  patient  said  he  felt  much  better.  Later  he 
had  a  period  in  which  he  had  lost  self-control  and  could  no 
longer  take  any  initiative.  Thus,  if  he  wanted  to  reply  to 
his  mother,  it  seemed  to  him  that  some  one  not  himself  was 
ordering  him  to  write.  He  now  asked  himself  if  he  were  not 
really  dreaming.  He  would  not  be  sure  of  his  actual  exist- 
ence unless  something  happened  to  prove  it,  such  as  the 
nurse's  bringing  him  a  plate. 

In  short  as  the  first  phase  of  diffuse  over-emotionality  had 
been  succeeded  by  a  second  of  obsessions,  so  the  obsessive 
phase  was  succeeded  by  a  third  phase  of  mild  loss  of  the 
feeling  of  reality.  The  first  phase  following  the  wound  was 
one  of  disorder  of  attention,  of  memory,  and  in  fact  of  all  the 
mental  functions,  associated  with  tremors,  tachycardia  and 
dizziness.  The  second  phase  seemed,  as  it  were,  to  crystal- 
lize intellectually  the  anxious  apprehensiveness  of  the  first 
phase.  There  were  fears  that  the  ceiling  would  fall;  there 
were  scruples  concerning  the  past;  there  were  fearful  pre- 
monitions for  the  future  (such  as,  that  any  bomb  he  might 
pick  up  would  burst).  According  to  Laignel-Lavastine  and 
Courbon,  there  may  have  been  a  predisposition  in  the  vegeta- 
tive system  of  this  subject,  or  even  a  basis  in  his  tuberculosis, 
of  which,  in  fact,  the  X-ray  showed  still  some  slight  evidences. 
The  obsessions  appeared  at  night,  at  a  time,  namely,  when  the 
vital  rhythm  is  passing  from  a  sympathotonic  period  over 
into  a  vagotonic  period,  at  a  time  when  the  organic  sensations 
are  apt  to  swim  to  the  fore.  According  to  this  analysis, 
these  somatic  sensations,  precisely  those  that  the  battle- 
field had  also  brought  out,  brought  out  again  the  other  emo- 
tions which  he  had  felt  on  service.  It  was  always  the  emo- 
tions first  developed  in  military  service  that  were  revived  in 
the  disease.  In  the  third  phase,  the  physical  condition  of  the 
patient  had  grown  much  better  pari  passu  with  disappear- 
ance of  the  obsessions  and  the  onset  of  the  personality  dis- 
order. The  adrenalin  raised  arterial  tension,  and  going  down 
to  the  sympathetic  caused  the  anxiety  and  war  emotions 
linked  therewith  to  disappear;   but  the  adrenalin  treatment, 


PSYCHONEUROSES  23 1 

according  to  Laignel-Lavastine  and  Courbon,  disturbed  the 
organic  sensations  so  suddenly  that  there  was  a  break  between 
the  new  conscious  status  and  the  old.  In  consequence, 
the  patient  felt  that  these  new  sensations  no  longer  really- 
belonged  to  him  but  were  of  a  xenic  character,  imposed  upon 
him  from  without  in  such  wise  that  he  continually  asked 
himself  whether  he  was  really  dreaming  or  no.  This  man 
was  a  constitutional  intimiste;  a  psychasthenic  en  herbe. 

Re  neurasthenia,  Lepine  notes  that  there  are  transient 
and  relatively  permanent  cases.  The  term  is  often  used  to 
cover  graver  disorders,  such  as  various  melancholias  and 
anxieties.  As  a  rule,  in  France,  the  neurasthenics  are  evacu- 
ated for  fatigue.  There  have  been  a  number  of  cases  in 
officers,  who  find  themselves  unable  to  make  decisions  on 
the  minute  and  to  remember  military  facts,  or  perhaps  are 
unable  to  make  any  physical  or  intelligent  effort  whatever. 
A  true  neurasthenic,  however,  ought  not  to  be  a  confused 
person.  He  is  a  man  with  a  rather  unusual  clarity  of  view 
as  to  his  situation;  and  his  trouble  appears  to  him  to  be 
somatic  rather  than  as  of  the  nature  of  a  depression.  He 
feels  that,  if  he  could  only  rest,  he  could  be  cured.  Neuras- 
thenia, according  to  Lepine's  war  experience,  is  practically 
always  the  disease  of  a  highly  cultivated  nervous  system, 
and  appears  in  men  who  have  undertaken  responsibilities. 
There  is  a  group  of  young  men  who  have  never  been  physi- 
cally strong,  bowled  over  at  last  by  some  small  event,  such 
as  a  diarrhoea,  and  unable  to  carry  on.  Such  men,  perhaps, 
are  likely  to  have  some  traces  of  an  old  tuberculosis,  an 
adrenal  insufficiency,  or  insufficient  hepatic  function.  Marti- 
net has  found  them  hypotensive  and  rather  poorly  aerated. 
There  is  another  group  of  neurasthenics  (Maurice  of  Fleury) 
that  are  old  arthritics,  with  increased  tension.  These  cases 
are  not  found  at  the  front  because  conditions  there  rather 
tend  to  reduce  the  trouble;  but  they  are  found  doing  office 
work  in  the  interior.  Besides  these  cases  of  the  "cultivated" 
group,  Lepine  also  finds  a  number  of  neurasthenics  amongst 
the  peasants,  in  whom  anxious  ideas  may  lead  to  hypo- 
chondria. 


232  PSYCHONEUROSES 


Fugue,  hysterical. 


Case  171.     (MiLiAN,  May,  1915.) 

The  fugue  of  an  adjutant  who  left  his  regimental  relief 
post  at  Palameix  Farm  and  was  found  several  days  later  with 
his  family  at  Castelsarrasin,  was  reconstructed  from  partial 
records  as  follows: 

November  27,  19 14,  after  a  night  in  the  trenches,  when 
two  shells  burst  near  him,  the  adjutant  turned  up  at  the 
relief  post  with  wild  eyes  and  a  complaint  of  fatigue,  and  of 
an  old  wound  and  headaches.  The  wound  he  had  gotten  in 
a  fight  which  gained  him  his  grade  of  adjutant.  The  physi- 
cian prescribed  rest.  He  sat  down  by  the  stove,  silent  and 
dejected,  and  at  about  four  o'clock,  in  the  presence  of  the 
medical  assistant,  made  preparations  to  go,  leaving  sack  and 
saber  behind,  but  taking  outer  garments  and  revolver  case. 
On  the  way  from  the  farm,  he  met  comrades  and  told  them  he 
had  been  evacuated  to  his  depot  on  the  colonel's  order,  and 
walked  with  them,  Indian  file,  in  the  midst  of  falling  shells, 
the  others  talking  but  the  adjutant  himself  silent.  At  night- 
fall, he  said,  "  Good  evening,"  and  parted  from  them.  Of 
his  further  course  to  his  home,  all  recollection  was  lost  by 
the  adjutant;  in  fact,  he  did  not  remember  anything  beyond 
the  Palameix  Farm,  where  he  had  seen  a  comrade  wounded 
in  the  head.  He  got  home  November  29th,  at  eight  in  the 
morning.  He  had  most  of  his  money  with  him,  having 
traveled  by  train  some  distance  without  a  ticket;  moreover, 
without  asking  for  a  ticket,  and  w^ithout  having  eaten.  When 
the  ticketman  in  his  home  town  asked  him  whether  he  was 
back  from  the  war,  he  looked  at  him  vaguely  and  went  out 
without  replying;  nor  did  he  reply  to  a  newspaper  man  on 
the  road  home.  This  was  the  more  strange  as  he  was  ordi- 
narily an  affable  person. 

He  had  a  convulsive  crisis  at  home,  after  which  he  was 
exhausted  and  apparently  unable  to  move  or  reply.  A  physi- 
cian said  that  he  had  had  a  cerebral  shock.  When  the  police 
arrived,  two  hours  later,  he  was  apparently  delirious,  saying 


PSYCHONEUROSES  233 

such  things  as,  "  The  Christians  want  to  shoot  me  hut  I  know 
the  rules!  Come,  hoys,  stay  in  the  trenches!  "  "There  are  two 
more  dead  ones!  "  etc.  During  the  day  he  recovered  con- 
sciousness and  was  greatly  disturbed  at  his  miUtary  crime. 

In  point  of  fact,  he  had  had,  at  the  age  of  17,  analogous 
crises,  as  was  certified  by  Regis,  who  had  cared  for  him  from 
1907  to  1909  for  hysteria  with  sudden  somnambulistic  at- 
tacks and  amnesia. 

While  in  prison  after  his  arrest,  he  also  had  hysterical 
crises  with  agitation,  flushed  face,  hard  attempts  to  vomit, 
respiratory  disorder  due  to  interference  in  the  throat  (globus 
hystericus),  and  delirious  phenomena  ("  Germans  had  fol- 
lowed him  home"). 

After  his  birth  his  mother  had  had  two  miscarriages 
and  a  stillborn  child.  The  adjutant  was  declared  irrespon- 
sible and  acquitted.  This  is  apparently  an  instance  of 
hysteria  without  stigmata. 


234  PSYCHONEUROSES 

Hysterical  Adventist. 


Case  172.     (De  la  Motte,  August,  1915.) 

An  engineer,  31,  in  the  Landwehr  at  the  outset  of  the 
campaign,  was  first  put  on  sentry  service  in  BerHn  on  the 
ground  that  he  was  an  Adventist.  He  was  later  put  into  the 
military  service  and  had  difficulty  because  he  did  not  want 
to  serve  on  Sunday.  He  was  shoved  from  one  company  to 
another.  He  refused  to  be  inoculated  and  was  arrested 
therefor.  In  the  prison,  he  began  to  hear  God's  voice  calling 
to  him  distinctly  to  tell  his  fellow-men  that  the  end  of  this  was 
going  to  be  the  end  of  all  things.  Back  in  the  barracks,  he 
again  heard  a  voice  —  " Come  forth!  "  —  "Go!''  He  went! 
He  had  his  revelations  then  published  in  the  form  of  tracts, 
and  held  Bible  readings  day  and  night  among  his  friends  in 
Bremen  —  looking  for  the  signs  of  the  times  in  the  Bible 
sayings.  One  of  his  fellow  Adventists  finally  warned  the 
police,  and  the  military  authorities  put  him  under  psychiatric 
observation.  He  proved  to  have  numerous  stigmata  of 
hysteria.  He  talked  freely  about  his  visions,  and  was  aware 
that  he  was  punishable. 

Here,  then,  was  a  case  of  hysterical  psychosis,  liberated  by 
military  service. 


PSYCHONEUROSES  235 


Fugue,  psychoneurotic. 


Case  173.     (LoGRE.) 

The  question,  Is  this  escape  really  a  fugue?  is  brought  up 
not  only  in  epileptic,  alcoholic,  and  melancholic  cases,  but 
also  in  cases  suggestive  of  psychoneurosis.  A  son  of  an  in- 
sane person  was  subject  to  what  may  be  called  a  phobic  or 
obsessive  fugue.  The  case  may  be  called  one  of  morbid 
cowardice  and  was  observed  in  a  soldier  in  the  trenches.  In 
point  of  fact,  the  man  had  always  been  an  anxious  and  fear- 
some person,  given  to  phobias.  He  had  night  terrors  and 
fear  of  diseases  and  death.  He  was  agoraphobic  in  adoles- 
cence, and  had  to  have  a  policeman  or  passerby  go  with  him 
through  a  public  place.  He  had  had  also  suicidal  and  homi- 
cidal obsessions,  and  periods  of  psychoneurotic  anxiety. 

This  man's  sojourn  at  the  front  put  his  morbid  personality 
to  a  cruel  test.  He  was  soon  known  by  all  in  the  trenches  as 
a  froussard.  He  had  a  terrible  fear  of  the  guns,  jumped, 
grew  pale,  trembled,  complained  of  palpitations,  lumps  in 
the  throat,  etc.  He  was  the  laughing-stock  of  his  comrades; 
but  according  to  the  patient  himself,  he  was  more  afraid  of 
his  own  emotion  than  of  the  shells,  although  his  comrades 
couldn't  understand  it.  He  was  employed  as  a  kitchenman, 
in  a  post  not  much  exposed.  A  more  resolute  comrade 
helped  him  to  escape,  escaping  also  himself,  thus  bringing  up 
the  problem  of  fugue  d  deux.  Limited  responsibility  was 
decided  for  the  case,  although  the  fugue  had  been  aided  by  his 
morbid  anxiety.  Of  course,  his  place  was  not  in  the  trenches 
at  all.  He  was  condemned  to  two  years  in  prison.  After 
his  sentence,  he  was  given  a  chance  to  rehabilitate  himself  by 
sending  him  again  to  the  trenches,  but  he  had  to  be  evacuated 
a  few  weeks  later  on  account  of  his  increasing  emotionality. 


236  PSYCHONEUROSES 


Shell-shy;    war  bride  pregnant:   Fugue  with  am- 
nesia and  mutism. 


Case  174.     (Myers,  January,  1916.) 

A  rifleman,  30  years  old,  was  brought  to  a  casualty  clearing 
station,  looking  like  an  imbecile,  with  a  history  of  having 
wandered  about  aimlessly,  not  knowing  where  he  was  or  what 
he  was  doing.  On  questioning,  he  remained  absolutely 
speechless  and  terrified.  Four  days  later,  in  conversation 
with  Major  Myers,  he  was  got  to  speak  in  a  faint  voice  about 
his  wife,  home,  and  occupation,  saying  that  the  month  was 
October  (when  it  was  actually  August)  and  that  he  had  been 
in  France  two  months,  when  it  was  actually  twelve.  He 
described  emotionally  certain  trench  scenes,  and  then  thought 
of  his  wife  sewing 

Hypnotized,  he  remembered  going  into  a  dug-out  after 
running  away  from  shells ;  he  was  made  to  talk  in  a  loud  voice. 
Next  day,  during  hypnosis,  proper  orientation  for  time  re- 
appeared. He  was  got  to  write  an  ordinary  soldier's  letter 
to  his  wife.  The  following  day  he  was  active,  making  beds, 
but  was  mute  (there  was  a  case  of  mutism  in  the  same  ward) . 
Under  hypnosis  speech  returned.  He  had  gone  to  a  horse 
show,  and  upon  his  return,  something  hit  his  back;  shells  had 
begun  to  fall.  Found  hiding  in  a  shack,  he  was  carried  to  a 
hospital  in  an  ambulance.  After  this  hypnotic  treatment, 
the  power  of  speech  was  maintained,  although  his  voice  be- 
came faint  or  failed  whenever  he  was  asked  about  the  incidents 
described  above.  Next  day  he  waked  speaking  normally, 
nudging  his  neighbor  and  asking,  "Is  it  me  that's  talking?" 
He  had  before  appeared  dull  and  depressed,  but  now  appeared 
an  intelligent,  agreeable,  and  garrulous  fellow.  It  appears 
that  his  wife  was  a  war  bride  and  he  had  heard  some  months 
since  that  she  was  pregnant.  He  had  been  troubled,  thinking 
she  was  in  money  difficulties  and  kept  thinking  about  a 
friend  whose  wife  had  lost  her  first  baby.  Recovery  appears 
to  be  complete  except  for  occasional  headaches,  and  the 
patient  is  now  serving  in  his  reserve  battalion. 


PSYCHONEUROSES        ,  237 

A  neurasthenic  volunteer. 


Case  175.     (E.  Smith,  June,  1916.) 

A  man  who  volunteered  for  service  at  the  outbreak  of  the 
war  (he  had  recently  been  an  inmate  of  a  sanatorium)  was 
sent  back  to  England  as  neurasthenic  after  three  trying 
months  at  the  front.  The  case  sheet  read  that  he  was  subject 
to  dazed  conditions.  In  hospital  he  suffered  from  insomnia, 
and  before  his  slight  periods  of  sleep  he  constantly  had  visions 
of  two  comrades  who  had  been  terribly  lacerated  at  his  side. 
These  hallucinations  in  their  reality  aroused  in  him  a  fear 
that  he  was  insane. 

There  were  also  terrifying  dreams,  beginning  with  episodes 
at  the  front  and  ending  with  sex  experiences.  These  dreams 
were  ended  by  seminal  emissions.  These  formed  a  second 
cause  for  the  patient's  belief  that  he  was  insane,  as  he  said  he 
remembered  literature  read  as  a  boy  concerning  spermator- 
rhoea. 

In  the  treatment  of  this  case  the  writings  of  psychologists 
who  had  studied  hypnagogic  experiences  were  used  and  the 
absence  of  hallucinations  during  waking  hours  was  stressed. 
The  remembered  literature  regarding  spermatorrhoea  was 
discounted  by  the  rational  explanation  of  his  state. 

He  seemed  to  be  getting  on  well  when  a  trivial  accident 
caused  a  relapse.  While  he  was  saying  goodby  to  his  wife, 
who  had  visited  him,  she  was  taken  ill,  and  he  went  home 
with  her.  He  was  punished  for  being  late  in  returning  to  the 
hospital.  Although  no  moral  stigma  attaches  to  confine- 
ments in  barracks  in  most  soldiers'  minds,  in  this  man  a 
depression  was  produced  and  suicidal  talk  followed.  It 
seems  that  his  father  had  been  sent  to  jail  when  he  was  a  child, 
and  he  felt  he  had  been  tainted  by  his  father  in  such  wise  that 
his  "criming"  was  due  to  heredity.  With  the  removal  of 
this  misconception  he  became  more  rational  and  immensely 
improved. 


238  PSYCHONEUROSES 

Five  months'   war   experience;    Neurasthenia    in 
subject  without  heredity  or  soil. 


Case  176.     (Jolly,  January,  191 6.) 

A  38-year  old  soldier  is  Jolly's  example  of  a  neurasthenia 
produced  in  a  person  without  previous  neurasthenic  traits  or 
hereditary  factors.  This  soldier  had  been  a  moderately  good 
student  and  never  ill.  He  went  into  the  battle  line  in  De- 
cember, 1 9 14,  and  came  out  in  May,  191 5,  on  account  of  ex- 
haustion. The  case  is  not  wholly  convincing  since  the 
patient  had  a  shrapnel  injury  of  the  skull,  described  as  of  so 
inconsiderable  a  degree  that  he  was  not  put  on  the  sick  list 
on  its  account.  The  patient  finally  arrived  at  the  Nuremberg 
Hospital,  complaining  of  pressure  in  the  head,  as  if  there  was 
a  band  around  the  head,  and  dizziness.  He  wept  a  good  deal 
saying  that  the  sight  of  the  dead  had  frightened  him.  Sleep 
was  restless  and  there  were  unpleasant  dreams  of  the  battle 
field.  Intelligence  was  not  in  any  degree  disturbed.  The 
supra-orbital  points  were  sensitive  to  pressure.  The  tongue 
showed  a  marked  tremor  and  was  coated;  the  mechanical 
excitability  of  the  muscles  was  increased;  and  there  was 
reddening  of  the  skin  on  stroking.  There  was  a  fine  tremor 
of  the  extended  fingers,  less  tremor  of  the  head  and  of  the 
body  at  large.  Knee-jerks  normal.  Nutrition  well  pre- 
served.    Partial  recovery  in  the  hospital. 


PSYCHONEUROSES  239 


Importance  of  arterial  h3rpotension  in  the  diagnosis 
of  psychasthenia. 


Case  177.     (Crouzon,  March,  1915.) 

A  man  of  32  (never  well,  with  general  weakness,  ideas  of 
consumption  and  vacuous  thinking  following  a  good  recovery 
from  bronchitis  at  28,  unsuccessful  in  business,  subject  to 
weaknesses)  had  had  eighteen  months  antebellum  of  what 
might  be  called  psychasthenia.  There  were  spells  of  loss  of 
consciousness  without  convulsions,  and  probably  of  hysterical 
nature.  There  had  been  for  two  years  insomnia^and  a  general 
hypobulic  slowing  down  of  work. 

In  military  service  the  crises  became  more  frequent, 
coming  two  or  three  times  a  week.  Tuberculosis  could  not 
be  shown,  nor  was  there  any  organic  lesion  of  the  nervous 
system.  The  arterial  tension  (Potain  sphygmomanometer) 
stood  at  II. 

According  to  Crouzon,  arterial  hypotension  is  an  objective 
sign  tending'to  assure  the  organic  nature  of  a  psychasthenia. 
Whereas  simple  neurasthenics  are  hypertensive,  others  have 
long  been  recognized  as  hypotensive ;  but  heart  experts  have 
recognized  this  asthenic  hypotension  more  than  psychiatrists 
or  neurologists.  In  differential  diagnosis  it  is  necessary  to 
consider  and  exclude  the  early  hypotensions  of  pulmonary 
tuberculosis  and  those  of  Addison's  disease.  This  hypo- 
tension is  most  frequently  observed  in  constitutional  neuras- 
thenics and  psychasthenics.  Hypertensive  drugs,  adrenalin, 
tincture  of  colchicum,  have  produced  a  transitory  improve- 
ment in  a  number  of  cases,  but  the  amelioration  has  halted 
with  the  stoppage  of  the  drugs. 

Re  hypotensive  and  hypertensive  cases,  see  remarks  of 
Lepine  under  Case  176.  See  also  Case  169,  illustrating  some 
contentions  of  Green,  from  Mott's  clinic. 


240  PSYCHONEUROSES 


Service  in  France  and  Salonica :  Psychasthenia. 


Case  178.     (Eder,  March,  1916.) 

A  man,  29,  after  some  months'  service  (three  months  in 
France  and  later  in  Salonica)  was  invalided  for  backache, 
insomnia,  and  enuresis.  It  seems  that  this  married  man  had 
never  done  any  work  after  leaving  school  at  18,  having  sub- 
stantial private  means.  He  had  been  married  for  3I  years, 
had  a  son,  and  was,  according  to  Eder,  perhaps  morbidly 
attached  to  his  wife  and  child.  He  had  been  a  sportsman 
and  was  selected  for  sniping  work  in  France.  The  son  of  a 
shipbuilder,  he  had  always  planned  all  kinds  of  ships  and 
engines,  never  to  be  used.  After  seeing  the  world,  he  was 
about  to  enter  his  father's  business  when  he  had  to  take  care 
of  his  father  in  a  nervous  breakdown.  After  a  second  attack, 
the  man  never  entered  business. 

February  6,  19 16,  wide-spread  patchy  analgesia  and  lumbar 
hyperesthesia  were  found.  He  thought  sluggishly,  being 
restless  and  holding  attention  poorly.  He  began  twenty 
letters,  destroying  each  after  finishing  a  few  lines.  He  was 
shy  and  felt  that  everybody  was  looking  at  him.  He  became 
speechless  if  he  had  to  address  his  commanding  officer. 
He  had  an  obsession  to  mark  each  flagstone  and  touch 
each  post,  and  various  counting  and  arranging  obsessions. 

The  Horme  (Jung)  was  elusive.  A  dream:  "I  was  in  a 
cargo  boat  In  the  river;  we  were  steering  straight  into  ferry 
and  harbor.  The  pilot  rang  down  'Full  speed  to  stern';  I 
pushed  him  out  of  the  way,  and  rang  down  '  Full  speed  ahead, 
two  points  to  starboard.'  We  went  straight  past  ferry  and 
harbor  without  accident."  Again,  a  few  days  later,  "In  a 
motor  car,  came  to  some  rocks  which  sprang  up  In  front  of 
me.  The  machine  broke  down.  I  abandoned  it  and  clam- 
bered over  the  rocks.  It  was  tough  work.  My  object  was 
a  ship.  I  got  to  the  ship,  took  hold  of  the  wrench,  and 
rignalled  'Let  go.'  "  Herein,  according  to  Eder,  are  certain 
obvious  symbolic  conversions. 


PSYCHONEUROSES  24 1 


Antebellum  attacks,  with  dizziness:    Fainting  on 
horseback.     Neurasthenia. 


Case  179.     (BiNSWANGER,  July,  1915.) 

A  harness- maker,  37,  a  corporal,  was  called  to  the  colors 
on  the  second  day  of  mobilization.  He  was  attacked  by  a 
slight  dizziness  in  the  evening  (see  previous  history  below). 
He  went  into  the  field  on  August  7  and  had  repeated  attacks 
of  dizziness,  despite  which  he  took  part  In  several  skirmishes. 
He  could  not  ride  on  horseback,  since  dizziness,  ringing  in  the 
ears,  headaches,  and  trembling  of  the  whole  body  would 
develop.  October  27  a  severe  fainting  attack  came  while  he 
was  sitting  on  a  horse.  He  woke  ten  hours  later,  vomited 
several  times  and  felt  dazed.  Two  weeks  later  hearing  In 
the  right  ear  began  to  be  impaired.  During  several  transfers 
from  hospital  to  hospital  near  the  East  front,  there  were  two 
more  severe  attacks  of  dizziness  and  vomiting.  Brought 
back  to  Germany,  the  patient  finally  came  to  the  Jena 
Hospital,  May  20. 

The  estimate  of  this  case  depends  somewhat  on  the  previous 
history.  He  appears  to  have  come  from  a  healthy  family, 
was  married,  and  had  two  healthy  children.  His  bodily  and 
mental  development  had  been  normal;  he  had  been  an  un- 
usually good  scholar,  but  he  stammered  from  his  tenth  year 
without  apparent  reason.  He  had  had  treatment  In  an 
institution  for  stammerers  at  17,  achieving  a  complete  cure 
in  six  weeks.  His  military  service  was  as  a  cavalryman, 
1 897-1 900,  after  which  he  had  married.  There  was  no  excess 
in  alcohol;  he  was  not  a  smoker.  From  his  own  account,  he 
had  always  been  somewhat  nervous,  had  trembled  easily, 
and  had  fallen  to  stammering  when  excited.  In  19 13  there 
had  occurred,  after  physical  exertion,  three  violent  attacks  of 
fainting,  with  dizziness,  vomiting,  and  excessive  perspiration, 
each  attack  lasting  from  two  to  three  hours.  However,  from 
that  time  to  just  before  the  war,  he  had  been  free  from  attacks. 

On  examination  at  the  Jena  Hospital,  the  patient  com- 
plained of  general  weariness,  a  feeling  of  pressure  in  the  back 


242  PSYCHONEUROSES 

of  his  head,  a  hammering  all  over  the  head,  ringing  in  the 
right  ear,  impairment  of  hearing  in  this  ear,  a  feeling  of 
dizziness  on  raising  the  head,  palpitation  of  heart,  especially 
at  night,  occasional  trembling  of  the  whole  body,  and  ab- 
solute inability  to  walk. 

The  man  was  slenderly  built,  of  medium  height,  in  moder- 
ate nutrition;  pale  of  face  and  mucosae;  pulse  small,  regular, 
and  114.  Neurologically,  the  deep  reflexes  were  generally 
increased,  and  the  skin  reflexes  decreased.  Percussion  on 
the  back  of  the  head  elicited  marked  pain.  There  were  no 
pressure  points.  The  movements  of  the  arms  were  free; 
there  was  a  marked  tremor  of  both  hands,  more  marked  on  the 
right.  The  left  grasp  was  45,  the  right,  20,  by  the  dynamom- 
eter. 

When  lying  upon  his  back,  the  patient  could  move  his 
legs,  but  he  moved  them  only  slowly  and  with  tremor.  The 
heel-to-knee  test  was  successfully  executed  despite  the 
tremor;  nor  could  it  be  demonstrated  that  there  was  a 
genuine  ataxia.  Placed  upon  his  feet,  he  would  collapse, 
nor  could  he  be  made  to  walk  at  all.  With  trunk  supported, 
he  was  able  to  make  only  a  few  unsuccessful  attempts  to  drag 
the  feet  forward. 

Associated  with  this  apparent  paralysis,  the  sensitiveness 
to  touch  had  entirely  ceased  in  the  legs,  as  well  as  sensitive- 
ness to  pain.  The  zone  of  analgesia,  however,  was  more 
extensive  than  the  anesthesia,  spreading  upwards  three  or 
four  cm.  farther  in  front.  Ticking  of  the  watch  could  not  be 
heard  even  at  the  meatus  of  the  right  ear,  although  hearing 
of  the  left  ear  was  entirely  normal ;  bone  transmission  on  the 
left  side.  Whispers  could  be  heard  close  to  the  meatus.  On 
speaking,  the  patient  stammered  in  starting  sentences. 

He  looked  extremely  anxious  during  the  first  few  days  in 
the  Jena  wards,  claiming  that  he  could  not  raise  himself. 
When  his  trunk  was  raised,  he  would  let  himself  sink  feebly 
back  into  dorsal  decubitus.  However,  when  believing  him- 
self unobserved,  he  was  found  to  be  able  to  move  himself  in 
bed  somewhat  quickly.  He  was  able  to  get  a  box  from  be- 
neath the  bed,  to  open  the  drawer  of  the  night-scand,  and  to 
take  remarkable  care  of  his  moustachios.     He  complained 


PSYCHONEUROSES  243 

more  and  more  of  headache,  though  his  appetite  and  sleep 
were  good.     He  was  often  irritable. 

Treatment  at  first  consisted  of  cold  packs  of  the  legs  twice 
a  day,  salt-water  baths,  active  and  passive  exercises  of  the 
legs  in  the  position  of  dorsal  decubitus.  The  patient  de- 
claimed against  this  treatment.  There  was  slight  improve- 
ment after  a  w^eek  of  treatment.  He  was  then  able  to  raise 
himself  in  bed,  seat  himself  on  the  edge  of  the  bed,  and  stand 
without  support,  all  the  time,  however,  groaning  and  moan- 
ing. After  a  few  moments,  he  would  fall  back  on  the  bed, 
complaining  of  violent  headache  and  dizziness.  While  stand- 
ing, both  legs  trembled. 


244  PSYCHONEUROSES 


Antityphoid  inoculation :  Neurasthenia. 


Case  i8o.     (Consiglio,  191 7.) 

A  corporal,  39,  began  to  be  sleepless  and  weary,  with  head- 
ache, pains  in  the  back,  and  dizziness.  He  was  homesick. 
Upon  hospital  examination  he  was  very  variable  in  mood, 
rather  hostile  in  attitude,  and  at  the  same  time  suggestible. 
He  was  so  confident  of  being  sent  home  that  he  anticipated 
the  diagnosis  by  sending  his  belongings  back  to  Sicily  at  the 
time  he  was  transferred  to  hospital  from  his  regiment. 

After  a  month's  rest  and  psychotherapy,  the  man's  general 
condition  was  greatly  improved;  he  was  no  longer  sleepless 
and  had  no  longer  any  sign  of  neurotic  disorder.  He  still 
maintained  that  his  memory  was  weak,  although  In  point  of 
fact  his  memory  was  very  good  and  quick.  He  could  narrate 
all  the  facts  about  his  neurasthenic  state.  The  man's  com- 
plaints were  out  of  all  proportion  to  any  demonstrable  somatic 
disorder.  He  was  discharged,  cured,  to  be  put  to  work  at 
shoemaking,  with  the  diagnosis,  neurasthenia.  This  neuras- 
thenic state  developed  after  antityphoid  injection. 

Re  the  occasional  curious  effects  of  antityphoid  injection, 
see  Case  65. 


PSYCHONEUROSES  245 


Neurasthenia   (monosymptomatic :   Sympathy  with 
the  enemy). 


Case  181.     (Steiner,  October,  191 5.) 

A  non-commissioned  reserve  officer,  26,  in  civil  life  a  mer- 
chant, had  a  strong  hereditary  taint,  having  been  also  in 
peace  times  very  nervous  and  on  that  account  obliged  to 
give  up  his  studies.  At  the  age  of  14,  he  had  seen  a  man 
fall  down  from  a  roof  and  was  much  excited  about  it. 

At  the  beginning  of  mobilization  he  suffered  a  functional 
aphonia  for  a  few  days.  He  could  not  let  his  men  shoot  at 
the  enemy  because  of  an  idea  that  occurred  forcibly  to  him: 
that  the  enemy's  soldiers  had  wives  and  children!  He  felt 
badly  on  this  account.  Later  he  had  a  constant  taste  of 
blood  in  his  mouth  and  a  smell  of  corpses  in  his  nose.  Toward 
nightfall  all  these  symptoms  would  change  for  the  worse, 
and  the  symptoms  would  become  especially  bad  whenever 
he  had  anything  to  do  with  the  wounded.  He  tended  to 
weep  much  and  was  easily  frightened  and  had  also  various 
physical  symptoms  of  neurasthenia. 

Re  the  amazing  sympathy  with  the  enemy,  see  Case  229 
(Binswanger)  and  Case  (Arinstein),  in  which  chloroform 
lifted  from  a  German  and  a  Russian  consciousness  respec- 
tively opposite  emotional  tendencies. 


246  PSYCHONEUROSES 

Shell-shock  CLAUSTROPHOBIA :  Preferred  shell 
exposure  to  shell-proof  tiinnel. 


Case  182.     (Steiner,  October,  191 5.) 

A  colleague  of  Steiner,  an  army  physician,  35  years  of  age, 
with  strong  hereditary  taint,  having  two  sick  sisters  (one 
dementia  praecox),  had  been  incapacitated  for  work  through 
a  neurasthenia  a  few  months  before  mobilization.  However, 
at  first  he  felt  very  well,  marching  through  Belgium  and  into 
Northern  France. 

On  the  night  of  the  17th  of  October,  1 9 14,  a  shell  struck  the 
house  next  where  he  was  and  startled  him  up  out  of  sleep. 
After  that,  especially  at  nightfall,  upon  entering  a  cellar  he 
would  have  the  feeling  of  the  ceiling  falling  down,  and  he 
would  go  restlessly  from  one  space  to  another.  Afterwards, 
any  closed  room,  however  secure  or  distant  from  the  front 
and  free  from  shells,  would  give  him  the  feeling  of  the  ceiling 
about  to  fall  down.  He  could  no  longer  sit  quietly  anywhere, 
but  walked  about  and  avoided  the  company  of  others. 

A  characteristic  observation  is  the  following  as  described  by 
the  physician  himself:  There  was  an  absolutely  shell-proof 
tunnel  running  to  the  position  at  the  front  where  he  was  on 
duty.  It  took  about  25  minutes  to  go  through  the  tunnel, 
but  on  account  of  his  feelings  he  could  not  bring  himself  to 
use  this  tunnel  but  walked  over  the  exposed  hill  which  was 
frequently  shelled.  Curiously  enough,  after  the  appearance 
of  the  first  symptoms,  a  shell  exploded  nearby  without  any 
marked  psychical  effect.  This  happened  about  noon.  The 
obsessions  were  stronger  in  the  evening.  Objectively,  there 
were  neurasthenic  symptoms  of  a  bodily  nature;  there  was 
vasomotor  excitability.  He  was  depressed,  wept  easily,  and 
showed  lack  of  decision ;  he  had  tormenting  thoughts  that  he 
had  not  fulfilled  his  duty. 


XL     PSYCHOPATHOSES 
(GROUP   OF  VARIOUS   PSYCHOPATHIAS) 


A  case  of  Pathological  L3dng  occurring  in  a  soldier. 


Case  183.     (Henderson,  July,  1917.) 

No.  27369,  a  private,  attached  to  the  15th  Battahon  Dur- 
ham Light  Infantry,  was  admitted  Oct.  14,  1916,  to  Lord 
Derby  War  Hospital  from  Netley. 

September  11,  19 16,  he  had  been  admitted  to  Number  3 
GeneraLHospital,  France,  in  a  noisy,  excited,  insolent  state: 
said  he  saw  spirits  of  the  dead ;  heard  his  sister  urging  him  to 
lead  a  better  life.  Admitted  to  Netley  early  in  October,  191 6: 
now  said  he  was  a  spiritualist,  a  Frenchman,  had  a  quarrel 
with  parents  and  enlisted  in  British  Army,  in  army  service; 
went  to  France  August  12,  19 14,  was  wounded  at  Loos,  Sep- 
tember, 191 5,  returned  to  front  in  February,  191 6,  "shell- 
shocked"  June  I,  1916;  lost  consciousness  after  this  —  did 
not  know  where  he  was  until  July  22,  1916,  when  he  had 
been  arrested  as  deserter. 

Admitted  to  Lord  Derby  Hospital  October  14,  191 6,  — 
quiet,  orderly,  cooperative :  desired  to  return  to  his  regiment. 
He  now  gave  a  history:  Enlisted  British  Army  1908,  went  to 
France,  August,  1914,  wounded  February,  1915,  at  Neuve 
Chapelle;  recovered;  then  attached  to  45th  Durham  Light 
Infantry;  blown  up  July  22,  1916,  came  to  August  5,  1916, 
in  hospital  in  Boulogne;  then  back  to  his  regiment  —  but 
month  later  left  without  leave  to  pay  off  old  score  on  a  former 
comrade  who  had  insulted  his  sister  —  arrested  later  by 
military  police;  put  under  observation  In  65th  Field  Ambu- 
lance. No  deterioration  noted,  school  knowledge  fairly  well 
retained;  no  hallucinations  or  delusions  (maintained  he  was 
a  spiritualist,  also  that  following  shell-shock  had  suffered  from 
insomnia  and  seemed  to  hear  sister's  voice).  Physically^— 
small,  well  nourished,  efifemlnate  looking. 

Oct.  23,  1916,  he  broke  parole,  but  a  month  later  returned 
to  hospital  under  arrest.     The  police  reported  he  had  been 

247 


248  PSYCHOPATHOSES 

masquerading  as  wounded  French  soldier  attached  to  British 
army  as  interpreter;  imposed  on  people;  had  two  leaden 
types  in  his  possession:  "Interpreter  R.  le  Auldere,  attached 
to  1st  Division." 

Story  in  hospital  on  return :  —  Born  in  France,  did  well  in 
school,  entered  military  academy  at  Paris.  Quarreled  with 
father  —  ran  away  to  sea.  Adopted  by  a  French  lady  at 
Pembroke  Dock.  On  account  of  drunken  habits,  quarreled 
again;  joined  army  at  Bristol,  1908.  Went  to  France  in 
August,  1 9 14;  January,  191 5,  invalided  home  because  of 
"trench  feet"  —  discharged  as  unfit.  Reenlisted  June,  1915, 
in  Durham  Light  Infantry.  January,  1916,  again  ordered  to 
France.  Blown  up  on  Somme,  July,  191 6,  by  shell  —  remem- 
bered nothing  until  brought  to  Xo.  3  General  Hospital.  He 
remembers  being  accused  of  desertion  but  sentence  was  not 
passed,  as  he  was  held  by  the  medical  officer  to  have  been 
irresponsible  (as  a  matter  of  fact  he  was,  at  that  time, 
considered  to  be  a  case  of  dementia  praecox.) 

Said  that  during  twenty-five  days,  due  to  drunkenness,  his 
friends  had  taken  him  to  Manchester  with  them;  arrested  by 
police  as  he  attempted  to  get  back  to  hospital.  He  was  now 
accused  of  wilfully  lying  and,  confronted  with  his  police 
record,  at  first  denied  it,  but  later  gave  following  approxi- 
mately true  story: 

Born,  England,  1890;  early  life  of  a  roving  disposition, 
good  at  school,  liked  books  of  adventure.  Drank  early. 
Ran  away  at  sixteen;  was  returned  home.  Ran  away  again 
—  convicted  of  drunkenness.  Three- year  sentence  to  re- 
formatory in  1 910  for  stealing:  escaped.  Rearrested  for 
stealing  in  191 1:  released  in  1913,  enlisted  in  army  and  de- 
serted. Arrested  in  January,  1914,  for  stealing;  sentenced 
to  three  years:  released  to  rejoin  army  in  June,  1915. 
Arrested  as  deserter:  imprisoned  but  released  in  January, 
1 9 16;  left  for  France.  August,  19 16,  "shell-shocked,"  sent 
to  Field  Ambulance  No.  3,  General  Hospital,  Netley,  and 
Lord  Derby  War  Hospital.  Court-martialed  for  desertion: 
nothing  came  of  it  on  account  of  medical  evidence. 

After  breaking  his  hospital  parole,  he  masqueraded  in 
district  as  "R.  le  Auldere,"  "Le  Marchal  "  and  irnposed  on 
various  persons. 


PSYCHOPATHOSES  249 

Psychopath  ahnost  Bolshevik. 


Case  184.     (HovEN,  1917.) 

A  sergeant,  accountant  in  civil  life  (father  insane,  mother 
pulmonary,  grandfather  alcoholic,  cousin  insane;  patient 
himself  anemic  as  a  boy,  victim  of  chronic  gastritis  and 
gonorrhea) ,  was  evacuated  from  the  front  to  Chateaugiron  in 
March,  191 6.  It  appeared  that  instead  of  watching  over  his 
men  as  a  sergeant  should,  he  gave  utterance  to  baroque 
theories  of  the  divine  right,  the  influence  of  the  grace  of  God 
on  man,  and  the  end  of  the  war.  He  went  so  far  as  to  ask 
leave  to  transmit  to  the  Inventions  Bureau  of  the  War 
Ministry  an  invention  with  respect  to  the  problem  of  loco- 
motion, and  he  sent  to  the  King  of  Belgium  a  manuscript  to 
the  effect  that  he  had  received  from  heaven  a  mission  to 
reestablish  the  world's  balance.  He  was,  in  fact,  the  victim 
of  delusions  of  a  mystical  nature  with  visual  hallucinations. 
To  explain  his  mission,  he  wrote,  "It  was  my  duty  to  take 
supreme  command  of  war  operations.  ...  I  have  the  power, 
the  right  and  the  duty  to  give  the  following  order  ,  .  . 
general  armistice  .  .  .  peace  will  be  symbolized  by  the  house 
undivided  and  will  be  constituted  by  general  Christian  relig- 
ious unity  ...  as  a  consequence  of  what  we  shall  say  they 
will  give  up  our  territory  to  us  of  their  own  accord." 

This  case  of  paranoia  apparently  took  Its  coloring  In  part 
from  the  war  situation  Itself. 


250  PSYCHOPATHOSES 

Hysterical  mutism :  Persistent  delusional  psychosis. 


Case  185.     (DuMESNiL,  1915.) 

A  sergeant,  aged  23,  evacuated  from  the  front  to  a  hospital 
for  the  insane,  had  been  mute,  though  not  deaf,  since  Febru- 
ary 28,  1915.  If  asked  to  cry  out  he  grew  black  in  the  face 
and  could  utter  only  a  raucous  scream  which  made  everyone 
jump.  He  wrote  very  frequently,  stating  in  February  that 
as  he  was  still  a  sergeant  and  had  no  hope  of  advancement, 
he  cared  nothing  more  for  life.  "The  idea  of  death  got 
anchored  in  my  head."  In  this  state  of  mind,  on  the  after- 
noon of  the  27th  two  bombs  came.  "I  saw  the  first  one 
coming  and  cried  out  a  warning.  Coming  back  I  saw  the 
second  one.  The  bombs  were  coming  rather  softly.  From 
this  moment  on  and  up  to  the  time  when  they  burst,  I  thought 
I  had  gone,  that  I  had  been  carried  off  and  crushed.  I  was 
quite  astounded  at  finding  myself  covered  with  earth  and 
stones  .  .  .  but  I  could  not  talk  any  more,  I  could  just  say 
in  a  low  voice  'Papa,'  and  the  next  day  in  an  ambulance  I 
could  not  talk  at  all." 

There  was  complete  pharyngeal  anesthesia.  The  man  had 
been  a  foundling  and  was  clearly  a  degenerate.  He  had 
always  been  of  a  depressed  disposition  and  given  to  thoughts 
about  his  misfortunes.  Over  and  above  the  mutism  gradu- 
ally ideas  of  persecution  and  revindication  developed  (such 
as  that  he  merited  adjutant's  rank  and  was  being  mocked  and 
treated  as  a  simulator).  He  drew  up  a  long  letter  to  the  War 
Ministry  in  which  he  stated  his  desire  to  be  sent  back  to  the 
front.  He  complained  to  the  police  about  a  hospital  sergeant 
and  offered  a  duel  in  an  elaborate  and  inflammatory  style, 
"with  whatever  weapons  shall  please  you,  either  sabre  of 
1845,  revolver  of  1902  or  bayonet  of  1886  or  the  chassepot. 
One  of  us  two  must  disappear."  He  had  become  dangerous 
enough  to  be  interned  and  in  hospital  remained  mute  with  the 
same  ideas  of  persecution  and  revindication,  the  same  alter- 
nate phases  of  calmness  and  excitation.  According  to  Dumes- 
nil :  hysterical  mutism  with  persecutory  delusional  psychosis. 


PSYCHOPATHOSES  25 1 


A  peasant's  psychopathic  inferiority  brought  out  by 
the  war. 


Case  i86.     (Bennati,  October,  1916.) 

An  Italian  peasant  began  to  feel  sick  on  being  called  to 
arms.  Antebellum  he  had  been  an  even-tempered,  good- 
natured  man,  according  to  his  own  story,  satisfied  even  with 
stale  food,  and  always  enjoying  his  sleep.  He  had  been  in 
the  war  about  a  month,  doing  construction  work,  sentry  duty, 
and  chores.  Though  he  lived  in  the  trenches  under  damp 
conditions,  there  had  really  not  been  much  excessive  war 
strain.  He  shortly  developed  migraine  and  war-weariness, 
as  well  as  middle-ear  disease. 

A  number  of  times  he  heard  shooting  nearby,  and  was  sub- 
ject in  his  sentry  duty  to  a  good  deal  of  anxiety  and  pain- 
ful associations.  On  sentry  duty  he  had  digestive  disorder, 
vomited,  and  became  intolerably  weary;  in  point  of  fact,  a 
fever,  regarded  as  malarial,  then  developed,  together  with 
diarrhea. 

Upon  hospital  observation,  he  was  found  fatigued,  given 
to  terrible  dreams,  tremulous  In  the  fingers,  with  skin  reflexes 
a  little  excessive,  and  the  Moeblus  phenomenon.  The 
thyroid  was  somewhat  swollen.  The  pulse  stood  at  80. 
The  Mannkopf  sign  was  well  marked,  as  well  as  that  of 
Thomayer  (80-120),  and  Erben  (120-87).  The  oculocardiac 
reflex  was  prominent. 


2.=i2  PSYCHOPATHOSES 


Psychopathic  episodes. 


Case  187.     (Pellacani,  April,  191 7.) 

A  Neapolitan,  26  (neuropathic  stock:  mother  epileptic, 
brother  psychopathic;  patient  had  previous  criminal  record; 
married  and  then  appeared  to  behave  himself  for  several 
years;  had  always  been  excitable  and  of  violent  temper), 
after  but  one  severe  day  in  the  trenches,  woke  and  found  his 
night  clothes  soaked  in  urine.  Another  time,  his  comrade  had 
awakened  him  because  he  was  gnashing  his  teeth  in  his  sleep. 
Again,  his  grief  became  very  violent  at  learning  of  his  wife's 
infidelity,  and  during  the  night  he  bit  his  finger.  He  there- 
after suffered  from  severe  headaches,  dizziness  and  vertigo 
though  without  falling.  He  was  granted  a  furlough,  but  the 
condition  was  aggravated  on  account  of  his  wife's  abandon- 
ment of  him,  and  one  day,  finding  her  with  her  lover,  he  threw 
himself  at  them,  wounding  her  severely  in  the  face:  he  did  not 
remember  this  impulse  later.  Many  hours  later,  on  awaken- 
ing in  prison  with  his  wounded  hand,  he  recalled  the  entire 
episode.  He  showed  a  confused  and  excited  condition, 
which,  however,  quickly  diminished.  He  became  lucid  and 
tranquil,  though  easily  aroused.  He  cried  at  the  thought  of 
his  daughter,  whom  he  wanted  to  save.  Insomnia,  insta- 
bility of  reaction,  habitual  migraine,  and  dizziness.  Tremors 
of  the  fingers  and  of  the  eyelids.  Exaggerated  reflexes.  Very 
striking  cutaneous  analgesia. 


PSYCHOPATHOSES  253 


Maniacal  and  hysterical  delinquent. 


Case  188.     (BuscAiNO  and  Coppola,  January,  191 6.) 

An  Italian  soldier,  25,  a  foundling,  was  always  off  and  on 
in  a  military  prison.  At  a  tavern  one  night  the  man  un- 
sheathed his  sword  and  threw  three  bottles  at  the  host. 
Bystanders  overpowered  him  and  carried  him  to  the  local 
police  station.  Handcuffs  were  put  on  to  stop  the  mania. 
His  pupils  were  dilated  and  he  was  sweating  profusely. 
Alcohol  could  absolutely  be  excluded  from  the  history  of  this 
incident. 

Observed  In  clinic,  the  patient  was  rather  silent,  but  on 
the  whole  normal  and  without  delusions  or  hallucinations. 
It  seems  that  he  had  committed  a  number  of  crimes  In  the 
army  that  were  always  excused  on  account  of  his  mental  state. 
He  had  been  strongly  alcoholic,  although  not  at  the  time  of 
the  Incident  mentioned.  He  was  covered  with  tattoolngs  of 
an  obscene  and  violent  nature. 

He  showed  pharyngeal  and  conjunctival  anesthesia  and 
concentric  limitation  of  the  visual  fields  of  unusual  degree, 
and  a  remarkable  hypalgesla.  The  knee-jerks  were  lively. 
The  man  was,  in  point  of  fact,  sent  back  to  military  service, 
with,  however,  the  suggestion  of  reform  school. 


254  PSYCHOPATHOSES 

Psychopathic  delinquent. 


Case  189.     (BuscAiNO  and  Coppola,  January,  1916.) 

An  Italian,  20  (family  history  negative),  was  described  by 
officers  as  of  an  odd  disposition,  at  times  thoughtful  and  again 
chattering  and  presumptuous,  and  often  very  vulgar  in  talk 
and  manner.     He  had  tried  several  trades,  with  little  success. 

While  in  the  army  he  discharged  his  gun  three  times,  claim- 
ing to  have  heard  noises  in  a  nearby  field.  On  account  of  the 
inopportune  repeated  discharges,  he  was  condemned  to  the 
barracks  for  ten  days.  The  following  day,  instead  of  return- 
ing to  the  barracks,  he  abandoned  his  musket,  cartridge  box 
and  uniform,  and,  returning  to  town,  left  for  Leghorn.  Being 
sent  to  prison,  he  began  to  scream  that  he  was  thirsty.  He 
tore  his  jacket  into  strips  with  his  teeth,  and  making  a  noose 
of  it,  attempted  to  hang  himself. 

On  being  transferred  to  the  military  hospital,  he  was  often 
very  restless,  screaming  and  making  a  great  uproar.  On 
being  questioned,  he  answered  indifferently  and  had  a  vacant 
stare.  During  his  stay  at  the  clinic,  patient  was  always 
quiet.  Once,  however,  he  had  a  spell  of  intense  psycho- 
motor agitation,  brought  on  without  any  known  cause  and 
followed  by  a  short  period  of  bewilderment,  lasting  altogether 
half  an  hour. 

Patient  had  insomnia  and  his  visual  fields  showed  con- 
centric contraction  for  white.  He  was  sent  to  a  military 
convalescent  hospital. 


PSYCHOPATHOSES  255 

Psychopathic  excitement. 


Case  190.     (BuscAiNO  and  Coppola,  January,  1916.) 

An  Italian  soldier,  22  (father  and  brother  both  committed 
to  insane  asylums),  since  his  enlistment  had  been  conduct- 
ing himself  strangely,  being  impulsive,  undisciplined  and 
unbalanced.  He  had  been  in  Libia  from  January  to  August, 
1 91 3,  and  was  returned  to  Italy  on  account  of  persistent  severe 
headaches.  A  month  later  he  was  returned  to  a  regiment 
in  camp. 

September  23,  1914,  the  patient,  who  had  been  reproved 
by  a  superior  officer  to  whom  he  had  given  a  disrespectful 
answer,  began  to  be  excitable.  He  was  calm  during  the  day, 
but  acted  in  a  sullen  and  gloomy  way  and  kept  entirely  to 
himself,  avoiding  even  his  most  intimate  friends.  When, 
however,  he  suddenly  recalled  his  punishment  of  the  morning, 
he  began  to  race  around  the  yard  and  finally  threw  himself 
upon  the  ground,  remaining  there  in  a  cowering  and  squatting 
position.  At  the  beginning  of  the  attack  he  was  possessed 
of  a  paroxysm  of  fury,  which  made  a  great  impression  upon 
those  present:  eyes  agape,  face  swollen  and  distorted.  He 
resisted  being  transferred  to  the  hospital  and  a  furious 
struggle  followed.  He  tried  to  bite  and  scratch  everyone. 
It  required  ten  persons  to  carry  him  by  his  hands  and  feet 
safely  to  the  hospital,  where  he  arrived  in  a  state  of  great 
excitement  and  rage. 

At  the  clinic,  during  the  period  of  observation,  he  was 
always  tranquil,  rather  silent,  gloomy,  somewhat  hostile; 
said  he  did  not  remember  why  he  was  brought  there.  Often 
he  was  not  able  to  sleep,  especially  during  the  first  few  days 
of  his  stay.  Has  had  painful  headaches  and  feeling  of  dizzi- 
ness. Several  times  he  showed  a  tendency  to  be  untruthful. 
Bodily  examination  revealed  the  absence  of  conjunctival  and 
pharyngeal  reflexes.     W.  R.  of  serum  was  negative. 

Patient  was  sent  to  an  interior  hospital  for  convalescence. 


256  PSYCHOPATHOSES 

Desertion:  Dromomania. 


Case  191.     (CoNsiGLio,  1917.) 

An  Italian  private,  19,  came  up  for  desertion  in  the  face  of 
the  enemy.  He  had  had  a  good  record  during  a  year  of 
military  service  and  his  army  conduct  in  the  war  was  regarded 
as  very  good. 

He  felt  sad  and  preoccupied  for  a  number  of  days,  but  all 
of  a  sudden  "some  indomitable  force  "  thrust  the  idea  into 
him  to  go  out  into  the  country  a  distance  of  some  20  kilo- 
meters from  the  front,  with  the  definite  object  of  praying  in 
a  certain  church.  It  seems  that  this  same  impulse  had 
occurred  to  him  several  times  before  but  not  so  forcibly. 
These  prayers  were  to  be  said  in  memory  of  some  sad  events 
in  his  life. 

Upon  examination  he  was  found  In  a  sad  and  self-accusa- 
tory state,  much  discouraged  with  ideas  of  his  guilt,  un- 
worthiness,  and  ruin.  He  had  a  variety  of  gloomy  fears  and 
obessions,  all  of  which  contributed  to  the  dromomania  that 
culminated  in  desertion. 

As  to  his  previous  history,  he  had  had  a  depressive  psy- 
chosis two  years  before,  but  the  delusions  at  that  time  were 
of  persecution.  He  had  also  suffered  from  typhoid  fever  a 
few  weeks  thereafter. 


PSYCHOPATHOSES  257 

Suppressed  homosexuality. 


Case  192.     (R.  P.  Smith,  October,  1916.) 

A  man,  32  years,  of  high  intellectual  attainments  and  un- 
blemished moral  character  —  a  teacher  —  enlisted  as  a  private. 
He  apparently  found  his  associates  in  camp  very  uncon- 
genial and  undesirable.  He  grew  physically  tired,  then 
mentally  tired  and  unable  to  concentrate  attention.  He 
began  to  neglect  his  uniform,  could  not  keep  his  equipment 
in  order,  became  introspective  and  depressed.  The  drums 
he  heard  seemed  to  point  to  his  funeral.  There  was  but  one 
thing  to  do  in  his  opinion :  that  was  to  humiliate  himself  by 
committing  sodomy.     He  thought  of  committing  suicide. 

Upon  discharge  from  military  duty,  he  began  to  show 
improvement.  Smith  regards  this  case  as  one  of  suppressed 
homosexuality. 

Of  the  cases  in  which  change  or  excessive  work  is  the  pre- 
cipitating cause,  four  out  of  six  of  Smith's  cases  were  men. 

Re  homosexuality  in  the  Italian  army,  Lattes  has  made  a 
special  study.  The  effeminate  homosexual  is  decidedly  unfit 
for  the  army,  being  unable  to  stand  the  war  stress.  Homo- 
sexuals diminish  army  morale.  The  cases  of  functional 
effeminacy  with  normal  physique  are  likewise  unfortunate 
for  the  morale  of  active  units,  though  they  may  be  employed 
in  garrison  duty  and  office  work.  The  medical  decision  in 
these  cases  may  prove  difficult  unless  a  broad  interpretation 
of  the  concept  "  psychopathic  "  is  allowed  to  prevail. 


258  PSYCHOPATHOSES 

Psychopathic :  suicidal,  then  self-mutilative. 


Case  193.     (MacCurdy,  July,  1917.) 

An  English  soldier  as  a  child  had  night  terrors  and  fear  of 
the  dark;  as  a  youth  wanted  to  throw  himself  down  from 
heights;  took  delight  in  seeing  animals  killed;  was  shy  with 
both  sexes;  was  never  able  to  run  great  distances;  was  taken 
from  school  at  the  age  of  fifteen  for  weakness,  and  had  always 
been  subject  to  headaches,  somewhat  improved  by  lenses. 

During  training  sharp  pains  appeared  in  the  left  groin  that 
grew  better  when  the  man  lay  down.  These  pains  were 
regarded  as  hysterical.  Thereafter  began  shortness  of  breath, 
pain  above  the  heart,  with  palpitations  and  occasional  attacks 
of  dizziness.  After  a  short  sick  leave  he  insisted  upon  going 
to  the  front,  though  his  superior  ofhcer  thought  it  unwise, 
and,  after  a  period  of  seventeen  months  training,  was  finally 
sent  to  France  in  September,  1916. 

He  was  at  first  somewhat  afraid  of  shells  and,  though  he 
soon  got  used  to  the  shells,  the  horror  of  the  war  grew  on  him, 
with  pity  for  the  Germans  as  much  as  for  the  British.  He 
became  depressed  over  his  weakness  and  when  his  command- 
ing ofhcer  committed  suicide  got  obsessed  with  the  idea  of 
committing  suicide  himself.  He  went  so  far  as  to  drive  a 
knife  into  his  upper  lip  and  to  smash  a  looking-glass  to  avoid 
seeing  himself.  After  a  long  spell  of  trench  duty  he  had  to 
be  sent  home  incapacitated. 

In  hospital  in  England  he  was  depressed  and  suicidal. 
He  began  to  want  to  mutilate  himself,  yet  found  that  a  slight 
pain  and  the  drawing  of  blood  was  all  that  he  really  craved. 
Of  course,  he  had  been  a  failure,  but  now  he  rationalized  the 
failure  by  a  comfortable  conviction  that  he  should  never  have 
been  sent  to  the  front.  He  complained  of  memory  and 
attention  disorder,  insisted  that  he  was  physically  incapable 
of  outdoor  exercise,  complained  of  headache  if  he  stayed 
indoors.  He  said  he  wanted  to  go  back  to  the  front;  knew, 
however,  that  he  could  not,  and  even  refused  to  consider  the 
possibility  of  getting  well  to  work  at  home.  At  the  time  of 
report  he  argued  there  was  nothing  left  but  suicide. 


PSYCHOPATHOSES  259 

Bombardment :  Psychasthenia? 


Case  194.     (Laignel-Lavastine    and    Courbon,    July, 

1917.) 

A  twenty-year  old  engineering  student  of  high  grade  and 
without  hereditary  taint,  a  scientific  and  non-introspective 
man  of  a  brilliant  and  gay  disposition,  not  very  religious,  with- 
out special  sexual  abnormality,  was  mobilized  in  class  19 14, 
was  put  into  the  artillery,  and  was  soon  appointed  marechal 
des  logis.  He  left  for  the  front  April,  191 5,  yet  had  to  be 
evacuated  in  November.  One  afternoon,  at  the  end  of  a 
bombardment,  he  rose  from  a  recumbent  attitude  and  imme- 
diately felt  a  dreamy,  bizarre  feeling,  as  if  a  fog  lay  between 
him  and  his  surroundings.  Next  day,  after  a  good  night, 
he  woke  in  the  same  state.  Everything  was  bizarre  and 
novel  despite  the  fact  that  he  recognized  men  and  things. 
A  physician  ordered  rest  and  after  a  few  days  evacuated  him. 

He  was  cared  for  in  various  hospitals,  but  the  psychas- 
thenia increased.  He  felt  a  terrible  and  causeless  anguish, 
with  precordial  constriction.  He  felt  as  if  he  were  about 
to  be  executed.  His  fears  appeared  after  seeing  some  turn- 
ing object,  such  as  a  wheel  or  a  cane  twirling.  Gradually 
this  fear  was  transformed  into  a  genital  excitation,  though 
lascivious  pictures  did  not  excite  him.  Seeing  anything 
turning  gave  him  a  voluptuous  feeling  in  proportion  to  the 
speed  of  the  rotation.  It  seems  that  all  sexual  interest 
had  been  at  a  standstill  for  several  months  in  the  early 
part  of  his  disease,  when  suddenly  this  new  aberration 
appeared.  It  seems  that  a  portion  of  the  man's  work  in  the 
artillery  caused  him  to  use  screws  and  cogwheels  every 
day.  Attacks  of  vertigo  occurred,  with  the  appearance  of  an 
infinity  of  small,  colorless  spheres  turning  over  one  another, 
the  whole  forming  a  sort  of  animated  system  of  rotation. 
In  the  night  this  system  was  luminous  and  somewhat  like 
what  one  feels  on  compressing  the  globes  of  the  eye.  There 
was  a  retraction  of  the  visual  field.  The  man  would  be  found 
in  the  dream  state,  especially  after  waking  in  the  morning 
or  when  some  novel  kind  of  act  was  being  performed.     He 


250  PSYCHOPATHOSES 

got  somewhat  better  and  did  not  wish  to  go  on  leave,  be- 
cause he  feared  the  recurrence  of  these  psychasthenic  par- 
oxysms. However,  he  took  a  leave  July  14th,  In  the  first 
part  of  his  journey  he  had  some  vertigo  and  some  of  the 
voluptuous  sensations,  but  in  the  next  two  days  he  was 
much  better.     He  returned  to  hospital  without  trouble. 

The  authors  somewhat  doubtfully  term  this  case  one  of  a 
quiet  psychasthenia,  but  in  discussion  still  further  talk  arose 
as  to  the  diagnosis. 

Re  psychasthenics,  Lepine  notes  that  the  lack  of  any  out- 
standing symptoms  in  many  psychasthenics  allows  them  to 
stay  in  the  army  longer  than  would  epileptics  or  hysterics 
of  the  same  degree  of  disease.  The  line  officers  tend  to 
consider  them  exaggerators  or  simulators.  The  fact  that 
they  besiege  the  line  officers  and  the  physicians  with  their 
troubles  may  add  to  the  impression  of  falsification.  The 
basis  of  the  psychasthenia  is  often  also,  genuinely  enough,  a 
fear.  Lepine  divides  the  military  cases  into  anxiety  neu- 
roses and  hypochondrias.  The  anxiety  cases  are  hypo- 
tensive and  given  to  tachycardia.  They  have  very  labile 
vasomotors.  When  it  comes  to  the  necessary  exclusion  of 
malingering,  it  is  the  history,  with  its  hereditary  and  col- 
lateral taint,  that  tells  the  tale.  A  history  in  the  patient 
himself  of  alcoholism,  typhoid  fever,  syphilis,  or  especially 
cranial  trauma  may  play  a  part.  An  agoraphobic  may  actu- 
ally be  in  general  a  courageous  man  except  for  his  crises  of 
anxiety  about  open  spaces. 

As  to  the  hypochondriacs,  fear  of  syphilis  must  be  noted. 
Akin  to  the  syphilophobics  are  a  group  of  pseudo  genito- 
urinary cases  that  fear  effects  of  an  old  gonorrhoea.  See 
Case  195  (Colin  and  Lautier)  below. 


PSYCHOPATHOSES  26 I 


Gonorrhoea:  NOSOPHOBIA,  depression,  suicidal 
attempt.     Recovery,  thirteen  months. 


Case  195.     (Colin  and  Lautier,  July,  191 7.) 

A  munition  worker  came  to  Villejuif,  December  6,  191 5, 
with  cord  marks  on  his  neck  and  conjunctival  ecchymoses. 
He  had  tried  to  hang  himself. 

Non-alcoholic,  he  had,  however,  long  since  shown  signs  of 
imbalance;  his  father  had  died  insane,  in  an  institution. 
When  the  man  came  in,  he  wept  and  groaned  and  made 
vague  complaints  of  having  contracted  a  venereal  disease, 
insisting  that  his  genital  organs  were  purple. 

After  a  few  days,  he  grew  less  anxious  and  told  how  he  was 
married  and  how  his  wife  had  made  life  a  hell  for  him,  giving 
herself  up  to  drink  and  becoming  a  sloven;  how  several 
months  since  he  had  contracted  gonorrhoea;  how  though 
told  that  the  condition  was  cured,  he  had  found  filaments  in 
the  urine  and  had  tried  a  variety  of  drugs,  spending  most  of 
his  money;  how  he  found  more  and  more  filaments,  thought 
himself  incurable  and  unable  to  live  with  his  wife;  how  at 
last,  desperate,  he  had  tried  to  hang  himself. 

He  got  well  quickly,  though  his  convalescence  was  in- 
terrupted by  several  periods  of  depression  a  few  days  in 
duration,  with  anxiety  and  tears.  February,  191 6,  he  was 
discharged  well. 

He  returned  four  months  later;  he  was  still  occupied  with 
his  disease,  still  going  to  physicians  and  buying  drugs.  It 
took  six  months  more  before  the  man  could  be  discharged 
from  the  service,  at  the  end  of  19 16. 

This  man  appears  to  be  a  hereditarily  predisposed  subject, 
who  simply  affixed  his  delusional  ideas  to  a  disease  which  had 
begun  some  time  before  the  mental  trouble  itself.  The  fam- 
ily plight  is  important  and  practically  constant  in  this  group 
of  cases.  The  fear  lest  the  disease  shall  be  revealed  by  the 
physician  to  the  family  is  deep-grounded  and  impossible 
to  overcome  by  mere  statements  concerning  professional 
secrecy.     The  impulse  to  suicide  is  extraordinarily  keen. 


262  PSYCHOPATHOSES 


A  soldier  (neuropathic  taint)  after  hardships  for  two 
days  stumbles  over  a  corpse;  unconsciousness: 
Stupor ;  episodes  of  fright  with  war  hallucinations ; 
look  of  premature  old  age ;  paresis ;  anesthesia. 


Case  196.     (Lattes  and  Goria,  191 7.) 

An  Italian  soldier  (a  shoemaker  with  an  epileptic  mother 
and  two  nervous  brothers;  himself  always  irritable  and  for 
long  periods  melancholic;  at  15  condemned  to  nine  years 
in  prison  for  homicide  in  a  quarrel)  took  part  in  a  num- 
ber of  attacks  at  the  beginning  of  the  war.  His  company 
was  heavily  engaged  in  October,  191 5,  and  there  was  no  sleep 
two  nights,  and  only  a  bit  of  cold  food.     He  was  dazed. 

October  24,  the  company  had  to  advance  at  night  in  the 
rain  and  under  a  heavy  rifle  fire.  The  shoemaker  stumbled 
over  a  corpse,  fell,  and  lost  consciousness  for  a  time  that 
he  thought  was  very  long.  He  woke  up  in  a  camp  hospital, 
remembering  all  the  experiences  he  had  undergone  up  to 
the  time  of  losing  consciousness.  He  now  fell  into  a  state 
of  torpor,  occasionally  jumping  out  of  bed  and  shouting  with 
fear,  hurling  himself  at  non-existent  persons,  assuming  a 
position  of  defence,  and  suddenly  awaking  in  anxiety. 

October  29,  he  was  transferred  to  a  second  hospital,  and 
October  30,  in  a  third  hospital,  was  examined  and  found 
well  and  strongly  built,  but  looking  prematurely  old.  He 
was  inactive,  depressed,  and  stuporous  looking.  He  fell  to 
weeping  often  and  rarely  gave  any  answer  to  questions. 
Sometimes  he  refused  food.  There  was  a  slight  paresis  of 
the  left  arm,  and  the  left  pupil  was  smaller  than  the  right; 
both  pupils  reacted  poorly  to  light.  The  larynx  and  cornea 
did  not  respond  to  stimulation.  Skin  reflexes  were  poor, 
and  the  plantar  reflex  lacking.  The  left  side  about  the 
shoulder  and  hip  showed  large  patches  of  anesthesia  to  touch, 
pain  and  heat;  but  deep  sensibility  was  present  in  these 
areas.  He  slept  well  at  night.  Status  unchanged  for  two 
weeks.  He  was  experimentally  sent  to  the  guardhouse,  but 
was  soon  back  in  hospital  with  the  same  symptoms  as  ever. 


—  la  buia  campagna 
tremo  si  forte,  che  dello  spavento 
la  mente  di  sudore  ancor  mi  bagna 

La  terra  lagrimosa  diede  vento, 
che  baleno  una  luce  vermiglia, 
la  qual  mi  vinse  ciascun  sentimento; 

E  caddi,  come  Tuom,  cui  sonno  piglia. 


—  the  dusky  plain 
trembled  so  violently,  that  the  remembrance 
of  my  terror  bathes  me  still  with  sweat. 

The  tearful  ground  gave  out  wind 
which  flashed  forth  a  crimson  light 
that  conquered  all  my  senses; 

And  I  fell,  like  one  who  is  seized  with  sleep. 

Inferno,  Canto  iii,  130-136. 


264 


B.   SHELL-SHOCK:    NATURE   AND   CAUSES. 


Bombardment;  shell  explosion  nearby:  Mania; 
death  in  24  hours.  The  AUTOPSY  showed  super- 
ficial punctate  hemorrhages  of  brain  and  congestion 
of  pia  mater.  CAUSE  OF  DEATH  —  small  bulbar 
hemorrhage,  congestion  of  veins,  and  nerve-cell 
changes  of  a  local  and  differential  nature  (chro- 
matolysis  of  vago-accessorius  nucleus).  SHELL- 
SHOCK  SYMPTOMS  due  to  capillary  anemia  and 
chromatolysis  of  various  regions. 


Case  197.     (MoTT,  November,  1917.) 

A  soldier  became  rather  nerv^ous  at  the  Somme,  and  later 
underwent  intense  bombardment  for  some  four  hours,  Feb- 
ruary 22,  4  to  8  P.M.  Although  he  said  he  "  could  not 
stand  it  much  longer  "  he  carried  on  for  twelve  hours  more 
when  perhaps  six  shells  went  over,  February  23.  One  of 
the  shells  burst  about  ten  feet  away,  just  behind  the  dugout. 
The  first  day  of  the  bombardment  he  was  tremulous  and 
depressed;  later  coarsely  tremulous  in  the  limbs.  February 
23  there  was  crying  and  inability  to  walk  or  do  any  sort  of 
work.  Questions  were  not  answered.  The  pupils  were 
dilated.  The  evening  of  February  23  the  man  was  admitted 
to  the  field  ambulance  in  acute  mania,  shouting:  "  Keep 
them  back!  Keep  them  back! "  He  was  quieted  with  mor- 
phine and  chloroform  and  slept  well  during  the  night.  There 
were  at  least  two  hypodermic  injections  of  morphine  in  the 
ambulance.  He  woke  up  the  morning  of  February  24  ap- 
parently well,  but  suddenly  died. 

The  autopsy  showed  small  scratches  on  the  anterior  chest 
wall,  but  otherwise  no  sign  of  external  violence.  Both  lungs 
were  edematous;  the  left  lower  lobe  showed  a  considerable 
hemorrhage.     The  heart  was  enlarged   and  the  right  side 

265 


266  SHELL-SHOCK:   NATURE  AND   CAUSES 


EFFECTS  OF  HIGH  EXPLOSIVE  SHELLS 

EMOTIONAL 
COM  MOTIONAL 
LESIONAL 

After  Vincent  and  others 


Chart  7 


SHELL-SHOCK:   NATURE  AND  CAUSES 

SHELli-  SHOCR 

1 


267 


SUGGESTION 

(auto-,      HETERO-,      MEDICAl) 


EMOTION 


SHOCK 


' L 


SOIL 

(acquired  ,  antebellum) 


TAINT 

(hereditary) 


ESSENTIAL! 

(Babinski) 

SOMETIMES  SOLE 
FACTOR? 


INTRABELLUM 

FACTORS 

USUALLY 

ONE    OR 

BOTH 


FREQUENT  BUT 
NON-ESSENTIAL 


-4 


FREQUENT  BUT 
NON-ESSENTIAL 


Chart  8 


268  SHELL-SHOCK:   NATURE   AND   CAUSES 

dilated.  The  liver  was  somewhat  congested.  The  kidneys 
were  small,  but  otherwise  showed  no  gross  change  (urine 
without  sugar  or  albumin). 

The  scalp  showed  a  slight  frontal  bruise.  The  brain  was 
extremely  congested.  On  each  side  of  every  superficial 
vessel  there  was  an  ecchymosis.  A  number  of  minute 
punctate  hemorrhages  was  found  on  the  surface  of  the 
brain  in  connection  with  very  small  vessels.  The  brain 
substance  was  soft,  but  not  markedly  edematous.  The 
cerebrospinal  fluid  was  tinged  with  blood.  On  each  side  of 
the  great  sinuses  of  the  skull  there  was  considerable  ecchy- 
mosis. This  examination  was  made  by  Capt.  A.  Stokes, 
R.A.M.C.,  in  the  mobile  laboratory.  There  were  no  areas  of 
large  hemorrhage  anywhere  in  the  brain  substance  and  no 
smaller  petechiae,  except  the  superficial  ones  above  noted. 

Microscopically  Mott  confirmed  the  pial  congestion  and 
macroscopic  subpial  hemorrhages  described  in  the  gross.  He 
found  besides  congestion  also  actual  hemorrhage  in  the  vas- 
cular sheaths  of  the  corpus  callosum,  internal  capsule,  pons 
and  bulb.  Now  and  then  blood  corpuscles  were  found  ex- 
travasated  into  the  nervous  tissue. 

The  microscopic  examination  showed  a  generalized  early 
chromatolysis  in  the  nerve  cells  of  varying  intensity,  espe- 
cially affecting  the  small  cells.  The  Nissl  granules  of  the 
larger  cells  were  also  somewhat  abnormal,  being  smaller  and 
packed  rather  loosely  together. 

The  small  cells  of  the  bulb  and  pons  were  slightly  swollen 
and  their  nuclei  large  and  clear.  As  to  the  larger  cells  of  the 
bulb  and  pons,  there  was  less  evidence  of  this  swelling  and 
nuclear  change. 

According  to  Mott,  this  chromatolysis  may  perhaps  be  re- 
garded as  a  sign  of  loss  of  biochemical  neuropotential. 
The  chromatolysis  indicates  a  relative  degree  of  exhaustion 
of  the  kinetoplasm.  Mott  assumes  that  the  cells  of  this 
victim  of  shell-shock  are  in  a  state  of  beginning  nervous 
exhaustion.  He  remarks  that  the  cells  of  the  vago-acces- 
sorius  nucleus  show  more  signs  of  this  nervous  exhaustion 
than  others.  With  respect  to  cerebellar  findings  Mott  re- 
marks that  the  changes  found  are  very  similar  to  those 


V. 


i^^^- 


Punctate  haemorrhages  in  corpus  callosum  from  a  case  of 
shell-shock  and  burial;  very  probably  accompanied  by  gas 
poisoning  while  lying  unconscious  and  buried.  Observe  the 
small  white  area  in  the  centre  of  the  haemorrhage,  in  the 
middle  of  which  is  a  small  vessel  which,  under  a  higher 
magnification,  will  be  seen  to  contaiu  a  hyaline  thrombus. 
(X  20.) 


Hyaline  thrombus  of  vessel  !n  centre  of  a  punctate 
hemorrhage.  The  thrombus  was  stained  brown  by 
dissolved  pigment.  Around  the  blocked  vessel  is  a 
white  area  of  brown  substance  containing  numbers  of 
leucocytes;  outside  this  is  the  haemorrhage,  not  very 
distinctly  seen,  ihe  specimen  was  prepared  from  the 
subcortical  white  matter  of  the  frontal  lobe.     (X  345.) 


Three  punctate  hemorrhages  showing  optostriate  arteri- 
oles filled  with  pigment  granules.     (X  30.) 


Leash  of  small  perforating  optostriate  arteries  filled 
with  pigment  granules.  Two  of  the  arterioles  show 
miliary  aneurisms.     (X  350.) 

HISTOPATHOLOGY  OF  CASE  OF  SHELL-SHOCK,  BURIAL, 
GAS  POISONING  ?     (F.  W.  MOTT) 


Fig.  I.  —  Photomicrograph  of  section  of  corpus  callosum 
from  case  of  shell-shock  showing  the  capillary  punctate 
haemorrhages.  In  several  a  small  white  area  is  seen  of 
brain  tissue  in  the  centre  of  which  is  a  small  artery  or 
vein.     (Magnification  20  diameters.) 


■  -4 

c 

'        ',,-            ' 

A    (v   ., 

^m 

ij    ^ 

/,                 W-  . 

Fig.  2.  —  Section  of  medulla  oblongata  from  case  of  gas 
poisoning,  stained  by  Nissl  method,  showing  the  swollen 
cells  of  the  nucleus  ambiguus.  Observe  the  enlarged, 
clear,  eccentric  nucleus;  the  surrounding  cytoplasm 
shows  an  absence  of  Nissl  granules.  In  not  a  single  cell 
is  the  nucleus  seen  in  the  centre  as  it  should  be.  (Mag- 
nification 450.) 


f  . 


A 


W'M 


Fig.  3.  —  Section  of  medulla  oblongata  from  case  of  shell- 
shock  with  burial,  stained  by  Nissl  method,  showing 
the  swollen  cells  of  the  nucleus  ambiguus.  Observe  the 
enlarged,  clear,  eccentric  nucleus;  the  surrounding  cy- 
toplasm shows  an  absence  of  Nissl  granules.  In  not  a 
single  cell  is  the  nucleus  seen  in  the  centre  as  it  should 
be.     (Magnification  450.) 


Fig.  4.  —  Section  of  third  cervical  segment  of  spinal  cord 
from  case  of  concussion,  stained  by  Nissl  method, 
showing  the  medium  group  of  anterior  horn  cells  corres- 
ponding to  the  nucleus  diaphragmaticus.  They  show 
certain  amount  of  perinuclear  chromatolysis.  But  all 
the  cells  exhibit  the  Nissl  granules.  Even  at  the  seat  of 
concussion. the  fourth  segment,  an  external  group  of  cells 
remains  showing  Nissl  granules.  Concussion  there- 
fore does  not  destroy  the  Nissl  granules.  Probably  the 
cells  of  the  nucleus  diaphragmaticus  show  a  certain 
amount  of  chromatolysis  because  they  were  continually 
discharging  impulses  along  the  phrenic  nerves,  and  the 
few  cells  that  were  left  of  the  nucleus  had  therefore 
much  more  work  to  do.     (Magnification  300.) 


HISTOPATHOLOGY  OF  SHELL-SHOCK  (F.  W.  MOTT) 

NOTE   THAT   THE    CH.'\NGES    IN    CELLS   OF    FIG.    3     ARE    DIFFERENTIAL    FOR    NUCLEUS    AMBIGUUS  : 

CELLS   NEARBY   PROVED    NORMAL 


SHELL-SHOCK:    NATURE  AND  CAUSES  269 

described  by  Crile  in  the  case  of  an  exhausted  and  wounded 
soldier.  Mott  correlates  the  mania  shown  on  the  evening  of 
February  23  with  the  venous  congestion  of  the  cortex,  the 
small  subpial  hemorrhages  and  evidence  of  scattered  arterio- 
capillary  collapse. 

Mott  suggests  that  the  sudden  death  of  the  case  may  be 
due  to  a  hemorrhage  into  a  sheath  of  a  fair-sized  vessel  in 
the  median  raphe  of  the  bulb;  the  general  venous  congestion; 
and  the  almost  complete  chromatolysis  of  the  vago-accesso- 
rius  nucleus  (adjacent  hypoglossal  nucleus  normal). 

According  to  Mott,  also,  many  Shell-shock  symptoms,  e.g., 
headache,  giddiness,  amnesia  (anterograde  and  retrograde), 
dizzy  feelings,  lack  of  power  of  attention,  and  fatigue,  stupor, 
inertia,  mental  confusion,  terrifying  dreams,  are  to  be  ex- 
plained on  the  basis  of  capillary  anemia  and  chromatolytic 
changes. 


270  shell-shock:  nature  and  causes 


Mine  explosion.  Ecchymoses;  no  bone  or  visceral 
consequences  seen  at  AUTOPSY  (third  day  after  ex- 
plosion) except  SUBDURAL  HEMORRHAGE  and 
PUNCTATE  HEMORRHAGES  OF  BRAIN. 


Case  198.     (Chavigny,  January,  1916.) 

A  sergeant  in  a  Chasseur  Battalion  was  in  a  mine  explo- 
sion and  entered  hospital  June  19,  1915,  so  agitated  that  he 
had  to  be  tied  to  the  stretcher  during  transfer  from  the 
railway.  There  were  remains  of  epistaxis  and  blood  in  the 
right  ear,  not  proved  to  be  due  to  otorrhagia;  blue-black 
ecchymoses  of  both  eyelids;  and  small  ecchymoses  of  the 
bulbar  conjunctiva  of  the  right  eye.  No  other  sign  of 
trauma  or  fracture.  The  explosion  had  probably  taken 
place  on  June  17  or  18.  Patient  was  but  semiconscious  and 
irresponsive;  rolled  upon  the  mattress,  beating  the  air  w4th 
arms  and  legs,  assuming  fighting  postures  and  uttering  cries. 
Urinary  incontinence.     No  fever. 

There  was  doubt  as  to  the  diagnosis,  which  lay  between 
fracture  and  concussion.  The  persistent  agitation  and  oniric 
delirium  pointed  rather  to  concussion.  Without  further 
sign,  however,  the  patient  died  on  the  night  of  June  20. 

The  autopsy  was  extremely  careful  and  showed  no  sign  of 
cranial  fracture  of  vault  or  base.  The  cerebrospinal  fluid 
was  strongly  bloodstained.  The  inner  surface  of  the  dura 
mater  had  a  thin  sheet  of  hemorrhage,  hardly  i  mm.  thick, 
covering  both  hemispheres  and  the  cerebellum  and  spreading 
over  the  bulb.  There  was  no  distension  of  the  lateral  ven- 
tricles. Serial  sections  of  the  brain  showed  no  lesions  of 
the  substance,  except  for  slight  hemorrhagic  points. 

According  to  Chavigny,  so  slight  a  meningeal  hemorrhage 
is  incapable  of  producing  a  mechanical  disturbance  of  the 
brain  and  the  cause  of  death  could  not  be  said  to  be  men- 
ingeal hemorrhage.  iMassive  multiple  gas  embolism  through 
sudden  decompression  is  not  a  suitable  explanation  of  a  case 
with  death  delayed,  as  in  this  instance,  even  if  Amoux's  ex- 
planation is  suitable  for  cases  of  immediate  death. 


SHELL-SHOCK:    NATURE   AND   CAUSES  27I 


Mine  explosion:  no  skin,  bone,  or  visceral  con- 
sequences seen  at  AUTOPSY  (death  in  seven 
days)  except  slight  LOCALIZED  MENINGEAL 
HEMORRHAGE. 


Case  199.     (RoussY  and  Boisseau,  August,  1916.) 

A  soldier  entered  Val-de-Grace  February  27,  1915,  in  a 
state  of  confusion  following  mine  explosion  the  night  before. 
He  was  delirious,  thought  himself  on  leave,  and  had  spells 
of  excitement.  Lumbar  puncture,  February  29,  showed  a 
slightly  darkened  fluid,  with  approximately  normal  amount  of 
albumin,  one  or  two  lymphocytes  and  rare  red  blood  cells. 

A  brief  period  of  slight  improvement  followed,  but  the 
restlessness  and  delirium  increased  once  more,  became  par- 
ticularly severe  March  3,  and  the  patient  died  on  the  night  of 
the  third,  seven  days  after  the  explosion. 

The  autopsy  showed  slightly  congested  lungs;  no  other 
lesion  except  a  sharply  defined  hemorrhage  in  the  cervical 
spinal  meninges  and  over  the  meninges  of  the  temporal 
and  occipital  lobes.  Microscopic  section  of  the  brain  failed 
to  show  any  hemorrhages  within  the  brain  substance. 

Here  is  a  case  of  death  following  explosion  without  external 
wound.  The  meningeal  hemorrhages  are  hardly  enough  to 
explain  the  death.  The  explanation  of  the  death  must 
probably  be  made  after  histological  examination. 


272  SHELL-SHOCK:    NATURE  AND   CAUSES 


Concussion  of  spinal  cord  from  shell  burst  —  WITH- 
OUT spinal  fracture,  WITHOUT  penetration  of 
splinters  of  shell  or  bone  into  canal  or  cord  sub- 
stance :  Microscopic  demonstration  of  intraspinal 
AREAS  OF  SOFTENING  with  classical  secondary 
degenerations.  Such  a  case  forms  a  link  in  the  ar- 
gument that  serious  lesions  of  the  nervous  system 
may  develop  as  a  result  of  VIOLENCE  directly 
TRANSMITTED  through  mvesting  tissues  EN 
BLOC. 


Case  200.     (Claude  and  Lhermitte,  October,  191 5.) 

A  man,  23,  was  struck  in  the  left  thorax  and  shoulder,  in 
both  thighs  and  the  neck,  by  fragments  from  a  bursting 
shell  March  27,  191 5.  One  fragment  was  imbedded  near  the 
vertebral  column. 

Twenty  days  later  there  was  an  absolute,  flaccid  para- 
plegia, yet  the  legs  occasionally  gave  spontaneous,  jerky 
movements.  Tactile  anesthesia  reached  the  fourth  dorsal 
root-level,  except  that  the  perineoscrotal  region  and  the  penis 
were  somewhat  sensitive.  There  was  anesthesia  to  pain  and 
heat,  as  well  as  in  bones  and  joints,  along  with  the  tactile 
anesthesia.  There  was  a  hyperesthetic  region  on  the  right 
side,  corresponding  with  the  distribution  of  the  fourth  dorsal 
root.  All  the  cutaneous  reflexes  up  to  the  abdominals  were 
gone;  but  defense  reflexes  could  be  brought  out  in  foot  and 
leg  by  skin,  bone  or  joint  stimulation.  The  deep  reflexes  of 
the  legs  were  also  lost,  whereas  those  of  the  arms  were  in- 
creased. Retention  of  urine  without  incontinence;  no  re- 
tention of  feces.  Sacral,  trochanteric  and  heel  decubitus 
had  developed  in  the  course  of  the  three  weeks  following 
injury.  A  lymphangitis  ran  all  the  way  up  the  right  thigh 
from  one  of  the  sores,  with  a  corresponding  hyperpyrexia. 

Surgical  intervention  was  indicated  from  the  evidence  of 
spinal  compression  at  a  definite  level,  but  the  lymphangitis 
grew  worse.  Oniric  delirium,  and  finally  a  stuporous  state, 
set  in,  with  death  May  6,  forty  days  after  the  wound,  a  death 


shell-shock:  nature  and  causes  273 

due  to  septicemia,  without  special  alteration  in  the  para- 
plegia itself  or  in  the  sensory  and  reflex  situation. 

At  autopsy  the  spine  and  dura  mater  proved  normal ;  but 
microscopically  serial  sections  through  the  fourth  and  fifth 
dorsal  segments  showed  softening  of  the  right  anterior  horn 
and  posterior  columns,  with  cavitation  in  the  radicular  zones, 
and  the  white  matter  of  the  fifth  dorsal  segment  was  in  a 
state  of  acute  degeneration.  There  were  also  ependymal 
changes,  namely,  at  the  fifth  dorsal  level  a  dilatation  with 
deposit  of  albumin;  in  the  lumbar  region,  breakage  of  the 
ependymal  wall,  with  cellular  gliosis.  The  dilated  ependyma 
was  surrounded  by  an  area  of  fibrillary  gliosis  which  had  pro- 
liferated in  the  form  of  a  septum  in  the  interior  of  the  canal. 
(According  to  Claude  and  Lhermitte,  these  data  concerning 
hydromyelia,  which  they  regard  as  secondary  to  trauma,  are 
an  argument  in  favor  of  the  traumatic  origin  of  certain 
syringomyelias.  They  regard  the  breakage  of  the  epen- 
dymal wall  as  due  to  hypertension  of  the  spinal  fluid  due  to 
mechanical  lesions.)  Their  interpretation  of  such  acute  de- 
generation as  was  found  in  the  fifth  segment  is  that  this 
degeneration,  as  well  as  that  of  the  posterior  roots,  is  due  to 
the  direct  impact  of  the  cerebrospinal  fluid  upon  the  cord 
structure.  As  for  the  softenings  with  cavitation,  they  re- 
gard them  as  surely  due  to  spinal  concussion  and  as  very 
possibly  due  to  an  ischemic  necrosis,  suggesting  that  older 
work  by  Duret  and  Michel  on  concussion  of  the  brain 
indicates  the  possibility  of  a  temporary  ischemia  of  the  spinal 
cord  from  the  violent  impact  of  the  spinal  fluid  upon  the 
cord  due  to  shock  of  the  spinal  column.  The  transient 
hypertension  of  the  spinal  fluid  might  well  induce,  they 
believe,  a  vascular  spasm  with  anemia,  to  which  the  gray 
matter  is  well  known  to  be  especially  sensitive.  In  the 
present  case,  a  period  of  somewhat  less  than  six  weeks  had 
sufficed  to  produce  secondary  degenerations  above  and  be- 
low the  fifth  dorsal  segment,  of  a  quite  classical  sort. 

Accordingly,  we  here  deal  with  a  severe  form  of  spinal  con- 
cussion due  to  a  shellburst,  in  which  intraspinal  lesions  were 
produced  without  spinal  fracture  or  penetration  either  of  bone 
or  of  shell  fragments  into  the  spinal  cord  or  the  spinal  fluid. 


274  shell-shock:  nature  and  causes 


Shell  explosion  (i  meter  distant)  kills  a  soldier  by 
bursting  both  lungs  within  the  intact  thoracic  cage. 


Case  201.     (Sencert,  January,  1915.) 

A  man  of  the  26th  Regiment  of  Infantry  was  brought 
October  26,  19 14,  to  Ambulance  No.  6  of  the  Twentieth  Army 
Corps  at  the  Chateau  d'Henu.  Weakly  and  jerkily  the  man 
was  able  to  tell  how,  as  he  was  going  forward,  a  large  calibre 
shell  fell  less  than  a  meter  in  front  of  him  and  exploded.  He 
fell  back  and  lost  consciousness,  was  picked  up  in  the  evening 
and  carried  to  the  relief  post  and  then  to  the  ambulance,  where 
he  arrived  ten  hours  after  the  fall.  There  were  signs  of  a  con- 
siderable shakeup,  with  pale  and  anxious  face,  nose  pinched, 
hollow  eyes,  rapid  superficial  respiration,  small  pulse,  120,  and 
a  feeble  voice.  There  were  small  skin  wounds  of  the  right 
arm,  a  finger,  and  ear,  but  there  was  otherwise  no^wound. 
The  thorax  and  abdomen  were  somewhat  painful  all  over,  but 
there  was  no  especial  point  of  pain.  The  chest  showed  a 
slight  dulness  at  the  bases.  Examination  of  the  abdomen 
produced  defensive  movements  and  the  man  vomited  blood 
during  examination.  He  was  put  on  his  back,  kept  warm, 
given  artificial  serum,  hypodermic  Injections  of  camphorated 
oil  and  caffeine,  and  carefully  watched.  In  the  night  he 
had  another  bloody  vomiting,  his  pulse  became  smaller  and 
smaller,  dyspnea  became  more  and  more  intense,  and  he  died 
late  In  the  night. 

The  autopsy  showed  that  the  abdomen  was  free  of  lesions 
and  that  all  the  organs  were  of  a  normal  appearance  and  color. 
There  was  no  sign  of  perforation  or  of  peritonitis.  The 
stomach  Itself  was  filled  with  blood  and  there  was  a  generalized 
ecchymotic  appearance  of  the  mucosa,  with  mall,  submucous 
hematomata  and  a  number  of  tears  In  the  pyloric  portion. 

The  pleurae  were  found  filled  with  blood,  almost  a  quart 
in  each  cavity.  The  right  lung  showed  a  large  tear  at  the 
level  of  the  middle  lobe,  15  cm.  long.  An  orange-size,  black 
bit  of  lung  protruded  through  the  tear.  There  was  no  sign  of 
rib  fracture  opposite  this  tear,  and  no  subpleural,  intercostal 


shell-shock:  nature  and  causes  275 

or  subcutaneous  contusion.  The  thorax  wall  was  perfectly 
normal. 

The  left  lung  showed,  in  the  middle  portion  of  the  upper 
lobe,  a  somewhat  analogous  pleural  tear,  almost  as  big  as  that 
on  the  right,  with  another  large  hernia  of  black  lung.  Bits 
of  the  herniated  lung  sank  in  water.  The  thorax  wall  was 
intact.  The  pericardium  was  free  from  blood.  There  was 
nothing  else  abnormal  about  the  body. 

Re  effects  of  an  explosion  upon  structures  with  intervening 
objects  left  intact,  Fauntleroy  notes  that  a  shell  bursting 
three  yards  from  an  aneroid  barometer  may  force  its  levers 
into  an  abnormal  position.  A  further  fact  will  indicate  how 
permanent  is  the  physical  state  into  which  the  levers  are 
forced;  for  when  the  barometer  with  its  levers  placed  right 
was  placed  under  a  bell- jar  and  the  pressure  therein  was 
reduced  to  410  mm.,  the  levers  resumed  the  position  into 
which  the  explosion  of  the  big  shell  had  thrown  them. 

Re  windage  and  internal  effects  in  the  human  body,  Ra- 
vaut  recalls  the  fact  that  the  internal  and  intraneural  hem- 
orrhages of  Caisson  disease  ("bends")  are  well  known.  The 
external  hemorrhages  of  aeronauts  and  mountain  climbers 
belong  in  the  same  physical  class.  Dynamite  exploded  in  a 
pond  kills  fish.  Dynamite  may  break  pillars  inside  a  build- 
ing without  damaging  its  front.  Cases  like  Chavigny's  (198), 
Roussy  and  Boisseau's  (199),  Claude  and  Lhermitte's  (200), 
as  well  as  Ravaut's  own  case  (202)  are  in  point. 


276  shell-shock:   nature  and  causes 


Shell  explosion  near  by :  Paraplegia,  interpreted  as 
due  to  windage.  Two  foci  of  HEMORRHAGE 
(SPINAL  CANAL,  BLADDER)  clinically  proved  to 
exist  in  a  case  without  external  sign  of  injury. 


Case  202.     (Ravaut,  February,  191 5.) 

An  infantry  sergeant  was  brought  to  the  ambulance,  one 
day  In  November,  19 14,  with  a  paralysis  which  had  set  in 
immediately  upon  the  explosion  of  a  large  shell  a  short  dis- 
tance away.  Both  legs  were  paralyzed  and  there  was  an- 
esthesia to  the  navel.  He  could  not  urinate.  It  was  early 
in  the  war,  and  Ravaut  thought  he  would  find  an  Injury  to 
the  vertebral  column,  but  on  undressing  the  soldier  there 
was  no  wound.  The  skin  was  Intact,  and  there  was  not  even 
an  ecchymosls.  The  patient  was  suffering  not  at  all,  but 
said  that  after  the  shell  exploded  he  felt  a  forcible  shock, 
was  stunned  for  a  moment,  and  when  he  wanted  to  rise,  found 
that  his  legs  were  inert.  His  state  did  not  change  during  the 
day  and  he  did  not  urinate.  Catheterization  showed  a 
urine  full  of  blood.  This  Indicated  a  lumbar  puncture,  and  a 
bloody  fluid  emerged  under  great  pressure.  Thus  two  foci 
of  hemorrhage  were  proven  to  exist  In  this  patient  despite 
the  fact  that  there  was  no  external  lesion. 

Re  windage  effects,  see  suggestions  of  Ravaut  under  Case 
201.  Ravaut  also  suggests  that  certain  cases  of  emotional 
jaundice  may  be  similarly  explained  on  the  basis  of  Internal 
lesion  due  to  windage.  Sundry  cases  of  gastro-intestlnal 
disorder  and  of  hemoptysis  fall  into  the  same  class;  possibly 
the  cases  of  death  in  a  fixed  posture  belong  there,  too. 
Ravaut  thinks,  despite  the  look  of  hysteria  about  the  shell- 
shock  cases  of  paraplegia,  deafness,  mutism,  and  the  like, 
that  the  cases  are  actually  ones  in  which  there  has  been  at 
the  beginning  a  slight  or  severe  hemorrhage,  clearing  up  in 
a  few  days.  He  states  that  there  is  a  pretty  definite  paral- 
lelism between  the  course  of  the  clinical  symptoms  and  the 
chemical  characteristics  of  the  spinal  fluid. 


SHELL-SHOCK:    NATURE  AND   CAUSES  277 


Shell-explosion  in  confined  space ;  paraplegia  after 
fifteen  minutes;  slight  hemorrhage  and  LYM- 
PHOCYTOSIS of  spmal  fluid;  Hematomyelia. 


Case  203.     (Froment,  July,  1915.) 

A  Sergeant  lying  down  in  a  small  dugout  space,  2  X  i  m. 
high,  had  a  77  shell  burst  behind  his  head  and  between  his 
head  and  the  back  of  the  dugout.  The  patient  was  not 
moved  by  the  explosion,  but  was  buried  in  a  small  amount 
of  earth  and  stones  to  a  depth  of  about  20  cm.  He  was  not 
wounded  and  showed  no  ecchymoses  either  then  or  later. 
Aided  by  stretcher  bearers,  he  was  able  to  walk  to  the  relief 
post  about  400  meters  from  the  trench.  He  did  not  lose 
consciousness,  and  got  to  the  relief  post  about  a  quarter 
of  an  hour  after  the  shell  burst.  Thereafter,  however,  he 
was  unable  to  move  his  legs.  The  accident  happened 
February  6  at  4  o'clock.  He  was  examined  24  hours  after 
the  trauma.  The  accompanying  diagrams  show  the  vari- 
ations in  sensory  disorder  at  intervals  during  six  months. 

A  lumbar  puncture,  February  8,  191 5,  showed  hypertensive 
clear  fluid  without  macroscopic  clot  on  centrifuging,  but 
showing  a  number  of  red  blood  cells  and  lymphocytes  — 
3  or  4  to  the  microscopic  field.  There  was  a  slight  hyperal- 
bumlnosls.  The  development  of  the  muscular  atrophy  and 
hypo-excitability  of  the  left  lower  extremity,  the  exaggera- 
tion of  the  left  knee-jerk,  together  with  the  spinal  fluid 
appearances,  seemed  to  prove  the  organic  nature  of  the  para- 
plegia. There  was  an  intense  rhachialgia,  with  radiation 
along  the  sciatic  nerve.  This  outlasted  all  other  symptoms. 
Thermo-analgesia  was  the  most  prominent  sensory  disorder. 
There  were  no  sphincter  disorders. 

During  the  first  days,  the  anesthesia  was  of  a  pure  seg- 
mentary type,  with  nothing  about  It  to  suggest  that  It  was 
later  to  be  supplanted  by  a  radicular  type  of  disorder.  Hema- 
tomyelia was,  years  ago,  thought  —  according  to  Froment  — 
to  tend  to  yield  sensory  disorders  of  a  segmentary  nature. 
At  the  outset  this  anesthesia  was  total,  though  there  was  a 


278  SHELL-SHOCK:    NATURE  AND  CAUSES 

vague,  poorly  localized  feeling  on  intense  painful  excitations, 
—  as  with  energetic  pricking  or  burning.  Thus  the  proto- 
pathic  sensibility  of  Head  had  remained,  whereas  the  epi- 
critic  sensibility  had  disappeared. 

Detailed  examination  of  this  case  showed  extreme  errors 
in  the  position  sense.  For  example,  pricking  the  foot  might 
be  localized  as  pinching  above  the  knee.  The  cremaster 
reflex  was  extremely  marked  and  would  appear  upon  even 
slight  excitation  of  any  part  of  the  lower  extremity,  even  at 
times  when  the  patient  declared  he  felt  nothing.  These 
phenomena  at  the  beginning  early  gave  place  to  a  syringo- 
myelic type  of  anesthesia. 

At  the  time  of  report,  July  29,  191 5,  Froment  regarded  this 
case  as  analogous  to  hematomyelias  of  divers,  although  there 
is  not  such  a  degree  of  decompression;  the  suddenness  of 
the  decompression  is  more  marked  in  these  Shell-shock  cases 
than  in  divers. 


shell-shock:  nature  and  causes  279 


Shell  explosion;  bowled  over;  loss  of  conscious- 
ness: Hemiplegia  with  reflex  signs  thought  to  be 
organic;  hypertensive  spinal  fluid;  LYMPHOCY- 
TOSIS. 


Case  204.     (Guillain,  August,  1915.) 

A  corporal  in  the  engineers  was  going  the  night  of  June 
7th  to  a  creneau  of  mitrailleuses,  when  he  was  bowled  over 
by  a  bursting  shell.  He  lost  consciousness  and  was  carried 
to  the  cantonment  by  his  comrades.  Next  morning  he  com- 
plained of  headache  and  pain  in  the  back;  had  a  convulsion; 
and  proved  on  examination  to  have  a  left-sided  hemiplegia. 
He  was  given  the  diagnosis  of  hysterical  hemiplegia. 

He  was  sent  to  the  6th  Army  neurological  center,  and  there 
showed  a  complete  left-sided  hemiplegia  with  tendency  to 
contracture.  The  left  knee-jerk  and  arm  reflexes  were 
exaggerated,  and  there  was  ankle  and  patella  clonus  with 
Babinski  sign.  There  was  a  dysesthesia  on  the  left  side, 
with  wrong  interpretation  and  poor  localization  of  painful 
stimuli,  and  non-recognition  of  cold  and  heat  sensations. 
Muscle  sense  and  stereognosis  were  impaired.  There  was  a 
slight  dysarthria.  Lumbar  puncture  yielded  a  clear  hyper- 
tensive fluid  with  a  slight  lymphocytosis. 

The  situation  remained  without  change  for  a  month,  when 
the  patient  was  evacuated  to  the  rear.  Thus,  a  shell-burst 
can  produce  destructive  nerve  lesions  without  evidence  of 
external  injury. 

Re  hypertensive  spinal  fluid,  Sollier  and  Chartier  cite  De- 
jerine  as  having  brought  the  proof  of  hypertension  in  the 
cerebrospinal  fluid  in  Shell-shock  cases.  They  also  believe 
that  the  Shell-shock  hysteria  is  built  up  on  a  physical  basis, 
more  or  less  after  the  model  of  Charcot's  hysterotrauma- 
tism.  Shock,  windage,  and  gas  may  bring  about  the  same 
kind  of  result.  They  rely  especially  on  the  cases  of  Sen- 
cert  (201)  and  Ravaut  (202)  for  their  argument  (1915). 
They  recall  the  fact  that  Charcot  found  a  hysteria  due  to 
lightning  stroke  and  to  high  tension  electric  accidents.  They 
quote  Lermoyez  as  attributing  like  results  in  ear  cases  to 
labyrinthine  shock,  tympanic  rupture,  and  ear  hemorrhages. 


28o  shell-shock:  nature  and  causes 


Shell-shock :  Hemiparesis,  amnesia.  Lumbar  punc- 
tures early  (but  here  as  late  as  one  month  after 
shock  and  after  disappearance  of  hemiparesis) 
showed  PLEOCYTOSIS  and  hyperalbuminosis. 


Case  205.     (SouQUEs,  Megevand  and  Donnet,  October, 

1915.) 
A  French  sergeant,  a  machine  gunner,  was  the  victim  of 

shell-burst  September  25,  191 5,  was  evacuated  with  a  diag- 
nosis of  commotio  cerebri,  and,  when  examined  at  Paul- 
Brousse  October  5,  showed  a  right-sided  hemiparesis,  clouding 
of  consciousness  and  somnolence,  the  hemiparesis  involving 
the  face,  with  deviation  of  tongue  to  right,  Babinski  reflex 
right,  cremasteric  and  abdominal  reflexes  abolished  on  right. 
Normal  respiration  and  pulse. 

Lumbar  puncture  October  7,  that  is,  thirteen  days  after 
the  injury,  yielded  a  clear  fluid  with  an  excess  of  albumin, 
144  small  lymphocytes  (some  degenerate)  and  a  single  en- 
dothelial cell. 

October  12,  the  knee-jerk  was  a  little  less  lively  on  the 
right  side.  The  plantar  reflex  varied  between  extension  and 
flexion  on  the  right  side.  The  cremasteric  reflex  had  been 
weakly  regained  on  the  right  side. 

The  patient  was  now  less  stupid  and  could  tell  how  he 
jumped  when  the  shell  burst,  and  how  he  had  been  in  the  air 
ten  minutes  (!)  and  fell,  getting  up  at  once,  with  nothing 
wrong  except  nosebleed.  After  a  half  hour  he  felt  weaker 
and  was  ordered  to  leave  the  post,  whereupon,  on  the  road, 
his  weakness  increased  and  he  tended  to  fall  to  the  right,  but 
reached  the  ambulance  on  foot. 

October  23,  there  was  no  longer  any  evidence  of  hemiparesis, 
the  Babinski  reflex  had  entirely  disappeared;  there  was  no 
complaint  except  of  dizziness  and  headaches.  He  got  back 
his  autocritique  on  the  matter  of  remaining  in  the  air  ten 
minutes,  but  there  was  still  an  amnesia  for  the  ten  day  period 
between  the  shock  and  his  arrival  at  Paul-Brousse.  He 
forgot  that  he  had  had  a  lumbar  puncture  October  7. 


SHELL-SHOCK:    NATURE  AND   CAUSES  28 1 

Another  puncture,  October  25,  yielded  some  14  or  15 
lymphocytes  to  the  cmm.  There  was  still  an  excess  of  al- 
bumin. The  lymphocytes  decreased  further  according  to  a 
puncture  November  2.  Had  this  patient  been  examined 
some  weeks  after  the  shock  there  would  have  been  no  signs 
of  an  organic  paresis,  no  special  modification  of  the  spinal 
fluid,  and  no  reason  for  regarding  the  man  as  other  than  an 
hysteric.     Early  spinal  puncture  is,  accordingly,  important. 

Of  course,  the  question  whether  the  lymphocytes  and  hyper- 
albuminosis  of  the  fluid  might  not  be  syphilitic  must  be  raised. 
At  the  Hospital  Medical  Society  meeting,  October  29,  191 5, 
Souques  states  that  Ravaut  and  Guillain  believe  that  simple 
shell-shock  often  produces  "  syphilitic  "  chemical,  physical 
or  cytological  changes  in  the  spinal  fluid.  Roussy  is  cited 
as  thinking  such  changes  rare. 


282  SHELL-SHOCK:    NATURE  AND   CAUSES 


Shell-shock ;  burial :  Coma  and  semicoma ;  BLOOD- 
STAINED SPINAL  FLUID.  Improvement  on 
puncture.     Persistent  astasia  abasia  with  spasticity. 


Case  206.     (Leriche,  September,  191 5.) 

A  man  was  buried  March  15,  191 5,  following  the  burst- 
ing of  a  large  calibre  shell.  He  is  said  to  have  had  hemopty- 
sis and  arrived  at  hospital  March  17  in  coma.  He  kept 
moaning  while  asleep.  March  18,  he  was  still  stupid  and 
as  if  stunned.  He  did  not  talk  or  understand  what  was 
said,  but  was  able  to  write  a  few  words.  The  knee-jerks  were 
a  little  exaggerated.  There  was  a  slight  spasticity  of  the 
limbs,  which  was  exaggerated  on  emotion  into  a  sort  of 
spasmodic  crisis. 

Lumbar  puncture  gave  a  reddish  fluid  under  strong  ten- 
sion. After  lumbar  puncture  the  man  came  out  of  coma  and 
the  next  day,  after  another  puncture  (fluid  slightly  yellow- 
ish), there  was  further  improvement  and  the  patient  spoke. 
The  third  puncture,  March  20,  yielded  yellow  fluid.  The 
spastic  phenomena  still  persisted,  however.  The  patient 
could  not  walk  or  stand.  Every  time  he  touched  the  ground 
he  had  a  clonic  crisis.  He  was  evacuated  to  a  neurological 
center. 

Re  astasia-abasia,  Nonne  found  these  cases  heading  a 
group  of  63  cases  of  war  hysteria  treated  in  a  twelvemonth. 
Figures  as  follows: 

Astasia-abasia 14 

Generalized  tremor 12 

Brachial  monoplegia 11 

Isolated  contracture 6 

Crural  paraplegia 5 

Mutism 5 

Isolated  tic 4 

Hemiplegia 3 

Isolated  respiratory  convulsions •>.  2 

Isolated  sensory  disorder I 

Fifty-one  of  the  63  cases  were  freed  by  therapy  from  their 
main  symptoms  (twenty-eight  cases  cured  in  one  or  two 
hypnotic  sittings). 


SHELL-SHOCK:    NATURE   AND  CAUSES  283 


Prolonged  bombardment;  shell  explosion  (near- 
by?): Depression;  suicidal  attempt;  hypertensive 
spinal  fluid. 


Case  207.     (Leriche,  September,  191 5.) 

A  patient  entered  an  evacuation  hospital  June  27,  having 
come  from  an  ambulance  with  a  ticket  reading,  "  Melancholic 
depression,  with  stupor  —  attempt  at  suicide  (threw  himself 
into  a  pond)  —  sprained  ankle  —  to  be  evacuated,  lying 
down,  on  a  milk  diet."  The  patient  was  depressed,  indiffer- 
ent to  surroundings.  Irresponsive,  and  did  not  even  look  at  an 
interlocutor.  There  was  no  other  somatic  sign  except  a 
pulse  of  62.  He  did  not  eat,  and  remained  lying  down,  with- 
out movement.  Lumbar  puncture  in  a  sitting  posture  yielded 
a  clear  liquid  under  pressure  of  34.  June  30,  another  lumbar 
puncture  yielded  clear  fluid  of  a  dichrolc  appearance  when 
looked  at  from  above.  25  c.c.  were  removed.  July  i,  there 
had  been  a  good  deal  of  Improvement.  The  patient  said  he 
was  better  and  began  to  take  a  little  milk.  July  2,  there  was 
still  some  improvement.  Pulse  60.  He  said  that  his  con- 
dition had  lasted  a  month  and  that  it  followed  a  violent  and 
prolonged  bombardment  for  ten  days  in  his  sector.  July 
3,  he  was  much  better,  began  to  look  about,  talk,  and  eat  a 
little.  July  4,  lumbar  puncture  yielded  a  clear  fluid  with  a 
pressure  of  30,  reduced  to  22  after  withdrawal  of  20  c.c. 

According  to  Leriche,  explosion  of  large  calibre  shells  or 
of  a  mine  can  produce  cerebral  or  spinal  symptoms,  some  of 
which  are  removed  by  lumbar  puncture.  The  fluid  is  red 
shortly  after  the  explosion  and  under  hypertension  for  some 
days.  Such  hypertension  may  be  found  even  in  shell  cases 
that  have  no  other  sign  of  cerebral  condition.  This  par- 
ticular melancholy  patient  had  a  relapse  and  another  de- 
pression with  fugue. 


284  SHELL-SHOCK:    NATURE   AND   CAUSES 


Example  of  HEMATOMYELIA,  indirect  result  of 
bullet  wound.     Partial  recovery. 


Case  208.     (Mendelssohn,  January,  191 6.) 

An  infantry  subaltern,  23  years  old,  was  injured  September 
24,  1 914,  by  a  rifle  bullet,  which  entered  above  the  left 
clavicle  and  emerged  between  the  right  scapula  and  the  ver- 
tebral column.  The  patient  leaped  into  the  air  when  he  was 
struck,  but  fell  at  once  and  found  that  his  legs  were  paralyzed. 
A  feeling  of  cold  crept  up  from  the  feet  to  the  region  of  the 
umbilicus.  Consciousness  was  preserved.  There  was  hem- 
optysis because  of  the  bullet's  passing  through  the  left  lung. 
The  wounds  all  healed  quickly.  There  was  retention,  fol- 
lowed by  incontinence,  of  urine  and  feces;  and  the  situation 
was  complicated  by  eschars  in  the  gluteal  and  trochanteric 
region. 

For  three  months  there  was  no  change  in  the  paraplegia, 
except  that  at  the  beginning  of  the  third  month  the  patient 
could  move  his  fingers  a  little  and  raise  his  knees  slightly.  He 
was  transferred  back  through  three  hospital  units,  with  a 
diagnosis  of  spinal  cord  lesion  or  fracture  due  to  a  vertebral 
column  lesion  at  the  second  and  third  dorsal  vertebrae. 

Seven  months  after  injury,  he  reached  a  Russian  hospital 
for  a  laminectomy.  Incapable  of  standing  or  walking  without 
support,  although  able  to  sit  and  rise  with  extreme  difficulty. 
He  could  now  very  slightly  flex  and  extend  the  knees,  and 
very  slightly  flex  and  rotate  the  ankle,  and  weakly  move  the 
toes.  Passive  movements  could  be  carried  out  without  much 
difficulty,  though  there  was  a  slight  joint  and  muscle  stiffness. 
Both  quadriceps  muscles  were  markedly  atrophied.  There 
was  slight  amyotrophy  of  the  lower  legs.  Tendon  reflexes 
were  exaggerated,  and  there  was  a  marked  ankle  clonus,  a 
Bablnski  reflex,  and  an  abolition  of  the  abdominal  a'nd  cre- 
masteric reflexes. 

There  was  a  sensory  disorder  of  an  incomplete  syringo- 
myelic pattern,  with  diminished  sensibility  to  heat  and 
complete  abolition  of  pain  sensibility.     Touch  and  electric 


shell-shock:  nature  and  causes  285 

sensations  were  somewhat  delayed.  There  was  a  diminution 
in  the  faradic  and  galvanic  excitability  of  the  legs  and  feet; 
vasomotor  disturbance  (slight  hyperidrosis)  of  the  paralyzed 
limbs.  Two  of  the  eschars  had  not  yet  cicatrized.  The 
sphincteric  disturbances  had  diminished.  For  the  rest  the 
patient  was  normal.  The  second  and  third  vertebrae  showed 
deformity  and  were  painful  to  pressure  and  percussion  of 
spinous  processes. 

The  patient  was  treated  by  galvanization  of  the  spine,  with 
a  current  descending  at  first  and  then  ascending,  and  by 
faradization  of  the  paralyzed  muscles.  There  was  progres- 
sive improvement,  irregular  but  constant.  At  the  time  of 
report,  July  i,  191 5,  he  was  perfectly  well,  able  to  take  long 
walks,  and  without  sphincter  or  sensory  disturbance.  The 
tendon  reflexes  were  still  exaggerated,  and  there  was  still  a 
slight  ankle  clonus  and  Babinski.  The  abdominal  and  cre- 
masteric reflexes  were  still  abolished.  The  last  of  the  seven 
eschars  had  not  yet  healed  over. 

For  the  organic  nature  of  this  lesion,  the  numerous  early 
eschars,  the  persistent  sphincter  disturbances,  the  limited 
paresis  of  the  legs,  the  reflex  disorders,  and  the  dissociation 
of  sensations  seem  abundant  evidence.  It  Is  probable  that 
there  was  no  fracture  of  the  vertebrae  (X-ray  confirmation), 
and  it  Is  probable  that  there  was  a  meningeal  hemorrhage, 
together  with  some  hemorrhagic  foci  In  the  spinal  cord  sub- 
stance, especially  in  the  gray  matter.  A  good  deal  remains 
doubtful:  Mendelssohn  remarks  that  the  sphincter  disturb- 
ances ought  to  be  related  to  disorder  of  the  fourth  and  fifth 
sacral  segments,  and  the  knee-jerk  and  Achilles  jerk  absence 
with  disorder  of  the  lower  lumbar  and  sacral  region;  the 
abdominal  reflex  disorder  with  the  low  thoracic  lesion;  the 
distribution  of  the  anesthesia  ought  to  indicate  a  lesion  In 
the  lower  part  of  the  spinal  cord.  Was  not  the  hemorrhage 
therefore  lower  down  than  the  spot  where  the  vertebrae  were 
displaced?  It  Is  surely  of  prognostic  note  that  the  eschars 
did  not  necessarily  foretell  a  fatal  outcome;  in  fact,  the 
patient  had  become  functionally  well  before  the  seventh 
eschar  was  healed  over. 


286  shell-shock:   nature  and  causes 


Shell  explosion  with  subject  l3dng  down  applied  to 
machine-gun;  no  contusion:  HEMATOMYELIA. 
Partial  recovery. 


Case  209.     (Babinski,  June,  1915.) 

A  veterinary  student,  six  months  captive  in  Germany, 
wrote  out  for  Babinski  the  following: 

"September  i,  1914,  I  was  about  to  operate  a  ma- 
chine gun  when  a  shrapnel  shell  exploded  very  near  me, 

—  probably  about  two  or  three  metres  overhead.  I 
base  this  estimate  on  comparisons  made  with  shells  I 
saw  exploded  beside  me  before  this  one. 

"Just  after  the  explosion,  which  deafened  me  and  at 
the  same  time  took  my  breath  away  a  little,  from  the 
powder,  I  felt  a  rather  severe  pain  in  the  kidney  region, 

—  a  pain  which  then  persisted  without  interruption. 
I  moved  my  left  arm,  to  find  the  effect  produced  by  a 
bullet  which  I  heard  whistle  by  my  ear  and  which 
struck  the  upper  part  of  the  left  shoulder  without 
entering.  At  the  same  time,  I  tried  to  turn  to  see 
what  had  become  of  my  legs,  and  had  a  feeling  that 
they  had  vanished.  Almost  immediately  I  felt  little 
prickings,  not  very  painful,  in  the  lumbar  region  and 
in  the  upper  part  of  the  thighs.  Just  then,  seeing  my 
comrades  going  away  I  tried  to  imitate  them,  but  could 
not.     All  these  feelings  passed  very  rapidly. 

"A  comrade  then  came  near  to  tell  me  to  go  back. 
I  told  him  that  I  could  not  move  and  that  I  must  have 
been  wounded  in  the  lumbar  region.  He  looked  at  my 
kit  and  my  coat  and  said  there  was  no  trace  of  shot  or 
tear.  Not  wanting  to  leave  me,  he  lifted  me  by  the 
armpits  and  knees.  I  could  not  help  him  get  me  up, 
and  my  legs  hung  flexed  and  inert.  After  a  few  steps 
he  had  to  put  me  down,  and  tried  to  stand  me  up.  I 
immediately  crumpled.  I  had  no  sensation  of  my  feet 
touching  the  ground.  I  sent  my  comrade  back,  asking 
him  to  tell  my  brother,  who  was  in  my  squad.  I  did 
not  lose  consciousness  or  any  feeling  of  my  situation,  or 
of  the  danger  being  run  by  my  comrade." 

The  man  remained  four  days  on  the  battle  field  without 
food.  He  was  on  the  edge  of  a  stream.  He  did  not  defecate, 
nor  for  two  days  did  he  urinate.     Eventually  the  bladder  and 


SHELL-SHOCK:    NATURE   AND   CAUSES  287 

rectal  functions  were  re-established,  thougli  they  remained 
irregular.  Catheterization  was  never  resorted  to.  The  lum- 
bar pains  were  diffuse,  fixing  themselves  a  few  days  after  the 
accident  in  the  region  below  the  umbilicus.  There  were 
pains  at  the  waist  predominating  on  the  left  side.  The 
paralysis  of  the  lower  extremities  grew  rapidly  better. 
Movements  in  the  right  leg  reappeared,  and  27  days  after  the 
accident  the  man  was  able  to  stand  and  walk  around  his  bed. 
Still  further  movement  followed  (left  leg  weaker) . 

At  the  time  of  the  report,  May  28,  1915,  the  patient  could 
walk  without  a  cane,  but  he  could  get  about  only  slowly. 
The  left  toes  would  rub  against  the  ground,  and  he  could  not 
support  himself  for  any  length  of  time  on  his  legs.  The 
knee-jerks  were  exaggerated,  especially  the  left.  The 
Achilles  jerks  were  increased.  There  was  a  Babinski  reflex 
on  the  left  side  and  an  abduction  of  the  fifth  toe  on  plantar 
stimulation.  The  same  reflexes  were  found  on  the  right  side, 
but  less  marked.  Abdominal  reflexes  absent,  except  the 
right  superior  reflex,  which  was  distinctly  present.  Cremas- 
teric reflexes  absent.  Anal  reflexes  preserved.  The  defense 
reflexes  were  exaggerated,  but  more  markedly  on  the  left 
side.  The  zone  from  which  the  defense  reflexes  could  be 
elicited  on  the  left  side  included  the  whole  lower  extremity 
and  rose  as  far  as  2  or  3  cm.  above  the  nipple.  Stimulation 
of  the  lateral  parts  of  the  left  lower  extremity  would  even 
produce  defense  reflex  movements  on  both  sides  of  the  body. 
On  the  right  side,  however,  the  defense  reflex  movements 
could  only  be  tried  out  by  scratching  the  anterior  surface  of 
the  ankle,  which  was  then  followed  by  a  flexion  of  the  foot. 

Sensibility  to  touch  and  deep  sensibility  were  preserved; 
but  sensibility  to  temperature  and  pain,  normal  on  the  left, 
—  ^'.e.,  paralyzed  —  side,  was  weak  in  the  right  leg.  There 
was  a  marked  sudation  on  the  left  side,  limited  by  the  white 
line,  the  inguinal  fold,  the  iliac  spines,  and  a  horizontal  line 
passing  through  the  umbilicus. 

Here,  then,  paralysis  followed  a  shell  explosion  while  the 
subject  was  lying  down.  No  contusion  therefore  was  pos- 
sible. According  to  Babinski,  we  are  dealing  probably  with 
a  hematomyelia,  the  result  of  shell  explosion. 


288  SHELL-SHOCK:    NATURE   AND   CAUSES 


Struck  by  missile  in  back;  unconsciousness;  no 
wound :  Hysterical  paraplegia?  HERPES  and  SEG- 
MENTARY HYPERALGESIA  suggest  radicular 
and  spinal  injury.     Recovery. 


Case  210.     (Elliot,  December,  1914.) 

November  i,  1914,  a  sergeant  in  the  20th  Hussars,  with 
other  dismounted  cavalrymen,  was  chasing  Germans  with 
a  bayonet,  over  turnip  fields  pitted  by  shells.  Several  hours 
later,  he  found  himself  in  a  house  in  a  nearby  village,  to 
which  he  had  been  carried  unconscious.  Probably  he  had 
been  struck  by  some  missile  in  the  back,  as  the  bottom  of  his 
haversack  had  been  torn  off.  His  face  was  blackened  with 
smoke,  and  his  clothes  were  muddy.  He  had  no  wound. 
His  left  arm  was  weak  and  his  legs  powerless  and  numb. 
The  passing  of  water  was  painful,  but  there  was  no  blood  in 
the  water  and  no  hemoptysis. 

Five  days  later,  he  was  examined  at  a  base  hospital  and 
found  to  be  paralyzed  and  numb  in  the  legs.  The  knee-jerk 
and  ankle- jerk  were  retained  upon  the  right  side  only.  Pain 
occurred  on  passive  movements  of  the  legs,  which  were 
flaccid;  there  was  a  hyperalgesia  about  Poupart's  ligament, 
more  marked  on  the  left  side.  Lower  abdominal  reflexes 
were  weak  on  the  left  side;  pain  in  lower  abdomen  with 
bladder  full  and  at  outset  of  micturition.  Pain  and  paresis 
also  affected  the  left  arm,  but  there  was  no  numbness.  Pain 
on  pressure  over  lumbar  and  cervical  vertebral  spines. 
There  was  no  evidence  of  bruising.  : 

The  physicians  were  Inclined  to  regard  tne  phenomena  as 
hysterical.  Three  days  later,  the  arm  movements  became 
much  freer,  and  after  another  three  days,  the  arm  move- 
ments were  fairly  powerful,  and  the  legs  much  stronger,  al- 
though the  patient  could  not  yet  stand  or  walk.  He  still 
had  pain  If  his  bladder  was  full. 

As  against  the  diagnosis  of  hysteria,  three  herpetic  clusters 
appeared  on  the  skin  of  the  left  thigh,  from  three  to  six  Inches 
above  the  knee.     Elliot  regards  it  as  certain  that  the  pos- 


SHELL-SHOCK:   NATURE   AND   CAUSES  289 


CAUSES   OF  SHELL-SHOCK 

HEAD   INJURY 
ATMOSPHERIC   CONCUSSION 
MENTAL   STRAIN 
NON-NERVOUS  TRAUMA 
NEUROPATHIC   HEREDITY 

After  Ballard 


Chart  9 


290  shell-shock:  nature  and  causes 

tenor  root  ganglia  were  injured.  He  regards  the  case  as 
one  of  injury  to  the  spinal  nerve  roots.  The  hyperalgesia 
about  the  body  of  course  suggested  damage  to  the  spinal 
cord.  According  to  Elliot,  therefore,  this  case  is  one  ot 
organic  disease;  whether  of  the  roots  or  of  the  cord  was  un- 
certain. At  any  rate  the  cases  of  this  type,  though  not 
functional,  recovered. 


SHELL-SHOCK:  NATURE  AND  CAUSES         29 1 


Mine-explosion;  burial;  labyrinthine  lesions  and 
head  bruises,  more  marked  on  left  side:  Focal 
canities  (WHITE  HAIR  developing  OVERNIGHT) 
on  left  side. 


Case  211.     (Lebar,  June,  1915.) 

A  soldier,  23,  in  the  Argonne  was  blown  up  by  a  mine  in 
a  trench,  fell,  and  was  covered  by  a  mass  of  earth,  from 
which  he  extricated  himself.  He  immediately  became  deaf 
from  what  was  medically  determined  to  be  a  double  hem- 
orrhagic labyrinthitis.  There  were  also  superficial  powder 
bums  of  the  face,  as  well  as  several  bruises  on  the  head, 
especially  on  the  left  side. 

The  next  day,  at  the  English  hospital  at  Arc-en- Barrois, 
the  patient  noticed  tufts  of  white  hair  on  the  left  side  of  the 
head.  There  were  four  islets  of  gray  hair  in  the  left  fronto- 
parieto-occipital  region,  separated  from  one  another  by  nor- 
mal hairs.  The  gray  hairs  were  gray  completely  from  the 
roots  to  the  ends  of  the  hair.  The  longest  hairs  were  as 
white  as  the  shortest.  There  was  not  a  brown  hair  amongst 
them.  The  gray  hairs  were  solidly  implanted,  and  could 
be  pulled  out  only  by  strong  traction.  There  was  a  dis- 
coloration also  of  the  bulbar  swelling  of  the  hair.  The  rest 
of  the  head  hair  was  dark  brown.  His  hair  was  described 
in  the  military  description:  "  deep  chestnut  brown."  There 
was  no  other  symptom  aside  from  an  incessant  twitching  of 
the  left  eyelids.  The  place  of  whitening  was  apparently 
determined  by  the  region  of  the  scalp  injured.  Not  only 
were  the  bruises  on  the  left  side  of  the  head  and  face,  but 
the  labyrinthine  lesions  were  more  marked  on  this  side  and 
the  twitching  of  the  eye-lids  was  confined  to  the  left  side. 


292  SHELL-SHOCK:    NATURE    AND    CAUSES 


Shrapnel  wound  of  skull ;  focal  canities  over  wound ; 
shell-shock  and  shrapnel  wound  of  right  leg.  Head 
tremors  and  contractions,  changing  in  relation  to 
posture;  glove  anesthesia  and  local  anesthesia  of 
trunk. 


Case  212.     (Arinstein,  September,  191 5.) 

A  Russian  private,  24,  was  wounded  twice:  once  in  the 
head  by  a  bullet,  and  at  another  time  by  a  bit  of  shrapnel 
that  imbedded  itself  in  the  skull.  The  hair  over  the  injured 
spot  became  gray. 

Later,  September  16,  191 5,  the  soldier  was  subjected  to 
shell-shock,  and  at  the  same  time  wounded  by  shrapnel  frag- 
ment in  the  right  leg  (operated  next  day). 

Upon  examination  at  Petrograd,  the  hearing  was  found 
diminished  and  the  eardrum  was  pulled  in.  At  first  the 
patient  could  not  speak  or  open  his  eyes,  and  made  incessant 
lateral  movements  of  the  head,  jerking  backwards  and  to  the 
right.  The  right  half  of  the  face  gave  convulsive  move- 
ments, which  began  at  the  lip  and  spread  upwards.  Dur- 
ing sleep,  there  was  an  entire  cessation  of  these  head  shakings 
and  jerks.  In  the  lying  posture,  the  head  shook  at  a  rate  of 
100  to  120  per  minute.  The  jerking  movements  became 
more  marked  when  the  patient  sat  up  or  walked.  He  carried 
his  head  bent  toward  the  right  shoulder.  When  he  sat  down, 
the  side-shaking  movements  disappeared,  only  to  reappear 
when  he  lay  down.  The  swallowing  reflexes  were  absent. 
The  sensitiveness  to  touch,  pain,  and  temperature  was  lost 
in  the  upper  part  of  the  trunk  including  the  neck,  to  the  level 
of  the  tenth  dorsal  vertebra.  There  was  anesthesia  of  the 
arms  as  far  as  the  elbow  on  the  right,  and  as  far  as  the 
shoulder  on  the  left.  The  mucosae  of  the  mouth  were  an- 
esthetic.    Dermatographia  was  strongly  marked. 


SHELL-SHOCK:    NATURE   AND   CAUSES  293 


Shell    explosion;     burial:     Hemiplegia,    probably 
organic. 


Case  213.     (Marie  and  Levy,  January,  1917.) 

A  soldier  was  blown  up  by  a  shell  and  then  buried  at  Vaux, 
March  29,  1916,  and  entered  the  Salpetriere,  July,  1916,  with 
a  right-sided  hemiplegia  and  contracture  without  evidence  of 
wound.  He  remembered  nothing  for  the  first  fortnight  after 
the  trauma.  When  he  came  to  himself,  he  was  paralyzed 
and  was  unable  to  say  more  than  a  few  words,  but  at  the 
end  of  a  month  his  aphasia  ceased  and  he  began  to  walk. 

The  hemiplegia  was  spastic.  There  was  pronounced 
contracture.  The  arm  was  extended,  hand  open,  fingers 
stretched.  Finger  movements  were  diminished,  as  well  as 
extension  of  the  wrist,  but  the  arm  was  otherwise  normal. 
The  leg  was  not  so  stiff.  The  great  toe  was  in  a  state  of  con- 
tinuous extension.  The  toes  could  not  be  moved,  and  the 
foot  scarcely;  but  the  leg  could  be  strongly  flexed  and  ex- 
tended on  the  thigh.  The  tendon  reflexes  of  the  right  side 
were  more  lively  than  on  the  left.  Clonlform  movements 
followed  tapping  the  patellar  tendon  on  the  right  side,  and  a 
patellar  clonus  and  ankle  clonus  could  also  be  demonstrated. 
Plantar  reflex,  flexor  on  the  right.  Distinct  adduction  of  the 
foot.  Slight  disturbance  of  tactile  sensibility  in  the  para- 
lyzed limbs;  marked  disorder  of  position  sense  and  gross 
disturbance  of  stereognostic  sense.     Moderate  dysarthria. 

Ten  months  after  the  traumatism,  the  hemiplegia  and 
spastic  walk  remained.  The  upper  limb  was  now  carried  in 
extension  back  of  the  body,  with  hand  supinated,  fingers 
sometimes  in  extension,  sometimes  in  flexion,  index  finger 
separately  from  the  others.  Finger  movements  difficult  and 
shoulder  movements  limited.  The  leg,  however,  was  almost 
normal  except  that  the  toes  could  not  be  moved.  The  tendon 
reflexes  were  more  lively  and  cloniform  on  the  right,  but 
there  was  no  longer  patellar  or  ankle  clonus.  Stereognosis 
slow,  but  finger  movements  were  naturally  difficult.  W.  R. 
of  blood,  negative.     Probably  this  is  an  organic  case. 


294  SHELL-SHOCK:    NATURE   AND  CAUSES 


Blown  up  by  a  shell;  no  skin  or  bone  lesion: 
Mixture  of  organic  {e.g.,  lost  knee-jerks)  and  func- 
tional {e.g.,  urinary  retention)  disorders. 


Case  214.     (Claude  and  Lhermitte,  October,  191 5.) 

A  man,  38,  was  blown  up  In  a  trench  without  sustaining 
skin  or  skeletal  lesions,  April  5,  191 5.  He  lost  consciousness 
for  a  half  hour  and,  coming  to,  found  a  crural  paraplegia 
and  urinary  retention.  Examined  July  24,  In  addition  to  the 
paraplegia  were  found  tactile  and  algesic  hypesthesia  of  the 
legs  with  preservation  of  deep  sensibility.  Pains  were  felt 
in  the  legs,  especially  In  the  hips.  The  knee-jerks  were 
abolished;  the  Achilles  jerks  were  preserved,  as  well  as  the 
flexor  plantar  reflexes  and  somewhat  weakened  cremasteric 
and  abdominal  reflexes.  Micturition  was  difficult.  Con- 
stipation. Slight  paresis  of  left  arm.  Lumbar  puncture, 
July  28,  yielded  a  clear  fluid  of  normal  tension  without 
chemical  or  cytologlcal  changes. 

The  sphincter  disorders  gradually  disappeared.  The  knee- 
jerks  reappeared  In  a  weakened  form  August  31.  The  legs 
could,  at  the  time  of  report,  be  moved  somewhat,  though  not 
above  the  level  of  the  bed. 

We  here  deal,  presumably,  with  a  mild  form  of  concussion 
of  the  spinal  cord.  In  which,  however,  some  of  the  transient 
symptoms  are  very  possibly  merely  functional  In  origin. 

Re  complicated  pictures  of  organic  and  functional  nature, 
some  experimental  work  has  been  carried  out.  Mairet  and 
Durante  set  off  explosives,  such  as  melinite,  at  a  distance  of 
I  to  1.5  metres,  near  rabbits.  Some  died  at  Intervals  from 
an  hour  to  thirteen  days;  others  lived.  Pulmonary  apo- 
plexy was  found  in  the  cases  dying  early.  Spinal  cord  and 
root  hemorrhages,  hemorrhages  In  the  cortical  and  bulbar 
gray,  perivascular  and  ependymal  hemorrhages  were  found, 
always  small  and  without  diffusion,  suggesting  rupture  by 
rapid  decompression  following  the  first  wave  of  aerial  com- 
pression. The  functional  effects  are  thought  to  be  brought 
about  through  the  anemia  of  the  areas  supplied  by  the  rup- 


shell-shock:  nature  and  causes  295 

tured  vessels.  Russca  of  Berne  got  similar  results  and  notes 
direct  and  contrecoup  brain  lesions,  tympanic  perforations, 
intra-  and  extra-ocular  hemorrhages,  thoracic,  cardiac,  and 
splenic  hemorrhages,  ruptures  of  kidney,  stomach,  intestine, 
and  diaphragm.  As  in  the  work  of  Mairet  and  Durante, 
the  lung  proved  the  most  sensitive  organ.  (Compare  also 
the  human  case  of  Sencert  [Case  201].)  Some  experiments 
with  fishes  yielded  lesions  of  the  swimming  bladder.  Per- 
salite  and  other  explosives  were  used. 


296  SHELL-SHOCK:    NATURE   AND   CAUSES 


GASSING :  Organic-looking  picture. 


Case  215.     (Neiding,  May,  1917-) 

A  German  soldier,  21,  was  a  serious  case  of  gassing.  He 
was  unconscious  two  days  (venesection  twice).  When  he 
came  to,  he  could  not  walk  and  felt  as  If  he  were  drunk. 
October  22,  1916,  he  was  Incoordinate  In  walking  and  tended 
to  fall  forward  when  standing  with  eyes  closed.  The  ataxia 
of  the  legs  was  demonstrable  In  the  position  of  dorsal  de- 
cubitus, and  there  was  also  a  slight  ataxia  of  the  arms.  The 
pupils  were  dilated  and  reacted  poorly  to  light. 

December  12,  all  symptoms  had  disappeared.  The  clinical 
picture  In  this  case  was  somewhat  like  that  of  a  multiple 
sclerosis.  According  to  Nelding,  the  disorder  is  not  a  func- 
tional one  but  an  organic  cerebellar  disorder. 

Re  the  neurology  of  gas  poisoning,  Nelding  regards  the 
condition  as  a  new  nosological  unit.  We  do  not  know 
what  the  ultimate  results  of  apparently  cured  cases  will  be. 
Court  questions  of  Importance  will  doubtless  arise  with  ref- 
erence to  their  compensation.  Ninety-six  of  Neldlng's  274 
cases  failed  to  show  any  nerve  symptoms  whatever;  forty- 
six  cases  showed  one  symptom  only,  such  as  headache,  diz- 
ziness, abnormality  of  reflexes,  or  abnormality  in  sensation. 
One  hundred  and  thirty-two  cases  presented  a  fairly  full 
picture.  The  picture  of  a  complete  traumatic  neurosis  not 
infrequently  appears,  aided  perhaps  by  the  psychic  features 
of  the  gas  attacks;  and  possibly  some  cases  are  entirely 
psychogenic  from  the  beginning.  Such  symptoms,  for  ex- 
ample, as  dermatographia,  rapid  and  Irregular  heart,  hyperid- 
rosis,  blepharospasm,  mental  perturbation,  hypochondria, 
etc.,  do  not  necessarily  point  to  any  directly  toxic  effect 
of  the  gases.  Thirty-seven  of  Neldlng's  cases  showed 
pupillary  changes,  hyperreflexia,  and  analgesia.  Thirty-one 
showed  analgesia  and  absence  of  laryngeal  and  corneal  re- 
flexes. Twenty-six  showed  pupillary  changes  and  hyperre- 
flexia, four  of  these  latter  showing  also  an  absence  of  laryngeal 
and  corneal  reflexes.  One  case  yielded  hyperalgesia  alone; 
ten  yielded  headache,  dizziness,  and  analgesia. 


shell-shock:   nature  and  causes  297 


GASSING:    Mutism,   tremors,  depression,   battle 
dreams. 


Case  216.     (Wiltshire,  June,  1916.) 

An  infantryman,  aged  27,  had  been  at  the  front  for  three 
months.  He  was  wounded  a  month  before  coming  to  hos- 
pital ;  but  when  the  wound  healed  he  went  back  to  the  front, 
quite  mute  but  intelligent  and  able  to  write  the  following: 

"We  were  on  our  way  to  the  trenches,  and  as  we 
were  going  through  the  railway  cutting  they  started  to 
shell  us,  with  gas  shells  mostly,  and  we  had  not  been 
there  more  than  quarter  of  an  hour  when  I  was  com- 
pelled to  lie  down  from  temporary  blindness  and  weak- 
ness through  getting  a  dose  of  gas  through  my  mouth 
and  eyes.  I  was  lying  down  for  about  ten  minutes 
when  a  shell  came  somewhere  near,  and  was  struck  by 
something  in  the  face  and  on  my  left  knee  and  I  re- 
membered no  more  until  I  found  myself  in  hospital. 
I  was  all  of  a  shake  and  while  lying  down  would  fre- 
quently jump  up  and  wonder  where  I  was." 

The  patient  had  been  mute  thereafter,  depressed,  and 
given  to  dreams  about  fighting  and  shells.  There  was  a  fine 
tremor  controllable  by  the  will;  the  knee-jerks  were  in- 
creased. On  lateral  deviation,  there  was  difficulty  in  fixing 
the  eyes.  There  was  a  slight  deafness  due  to  an  old  dis- 
charging left  ear.  According  to  Wiltshire,  Shell-shock  is  only 
exceptionally  caused  by  chemical  poisoning  from  gas. 

Re  poisoning  by  certain  German  asphyxiating  gases, 
Sereysky  reports  in  191 7  that  these  gases  contained,  among 
other  poisons,  a  nerve  poison.  He  found  that  poor  heredity 
was  a  favorable  soil  for  the  action  of  this  nerve  poison.  The 
clinical  pictures  In  the  gassed  soldiers  rather  suggested  cere- 
bral arteriosclerosis.  He  remarks  that  the  logical  distance 
between  the  "exogenous"  and  "endogenous"  is  greatly 
reduced  In  these  gassed  cases,  as  the  syndrome  of  "exog- 
enous" gassing  closely  approximates  that  of  various  "endog- 
enous" disorders. 


298  shell-shock:   nature  and  causes 


Hysterical  speech  disorder  related  to  mechanical 
disorder  of  auditory  apparatus. 


Case  217.     (BiNSWANGER,  July,  1915.) 

Whenever  a  German  officer's  servant,  23  years,  was  ad- 
dressed on  the  ward  in  the  Jena  Nerve  Hospital,  his  hands 
would  tremble  and  the  muscles  of  his  face  would  fall  into 
grimacing  associated  movements.  He  had  a  peculiar  Infan- 
tile type  of  speech,  talking  with  a  fixed  glance  and  an  anxious 
mien.  He  would  carefully  utter,  as  a  rule,  separate  words, 
chiefly  only  nouns  or  Infinitives.  He  would  gesticulate  with 
both  hands  to  make  what  he  said  understood.  Thus  (freely 
translating  the  German)  runs  his  description  of  a  battle: 

"Well  —  because  —  I  —  we  had  —  no  artillery  and  so 
many  losses  —  then  got  in  position  again,  then  we  —  laid 
down  a  long  time  —  perhaps  until  four  o'clock  In  the  after- 
noon —  five  —  and  —  and  It  happened  that  —  lay  In  Riiben- 
feld  —  couldn't  go  back  —  then  shell  near  me  —  fell  In  and  I 
right  near,  how  —  how  far  —  I  don't  know  and  —  grown 
better.  Comrade  said  —  10  meters  —  don't  know  —  un  — 
unconscious." 

Long  compound  German  words  could  not  be  repeated, 
since  after  the  first  or  second  syllable  there  was  a  severe  emo- 
tional excitement ;  syllable  articulation  and  phonatlon  ceased. 
Finally,  however,  the  patient  could  be  gotten  to  pronounce  the 
whole  word.  Reading  aloud  was  very  difficult :  syllable  sound- 
ing and  omission  of  difficult  syllables ;  after  a  time,  weeping. 

The  patient  was  a  somewhat  small,  muscular,  well-nour- 
ished man,  with  a  murmur  at  the  apex,  a  somewhat  rapid 
pulse,  increased  reflexes,  especially  skin  reflexes,  painful 
supra-  and  infra-orbital  points,  temples  painful  to  percussion, 
pressure  over  spine  painful  from  second  thoracic  to  third 
lumbar  vertebrae.  There  was  an  increased  sensitiveness  to 
touch  and  pain  over  the  whole  body.  There  was  a  bilateral, 
somewhat  marked  tremor,  more  marked  on  the  left  side  than 
on  the  right.  Swaying  in  Romberg  position  was  slight. 
Tremor  of  tongue. 


shell-shock:  nature  and  causes  299 

This  patient  was  first  brought  to  Jena  November  23,  1914. 
An  illegitimate  child,  a  moderately  good  scholar,  he  had 
worked  as  a  mason  until  he  went  into  the  army,  in  1912.  He 
worked  as  a  soldier  chiefly  in  the  officers'  casino  because 
he  got  pains  in  his  legs  and  knees  in  long  drills.  At  the 
outset  of  the  campaign,  however,  he  withstood  the  heavy 
marching,  although  with  difficulty.  He  was  in  his  first  actual 
skirmish  September  20.  A  shell  struck  nearby  and  threw 
him  several  meters;  whereupon  he  became  unconscious  and 
was  carried  away  by  the  hospital  corps.  When  he  woke  up 
he  could  not  speak  or  hear.  Ten  days  later,  however, 
speech  returned,  and  hearing  returned  in  right  ear;  October, 
deaf  in  the  left  ear,  and  he  could  not  hear  a  watch  tick 
on  the  right  side  at  a  distance  of  16  centimeters.  He  was 
examined  at  the  otologlcal  clinic  in  Jena  October  12,  where 
the  drum  membranes  were  both  found  opaque,  without 
reflexes  or  normal  contours;  hysterical  attack  on  the  caloric 
test.  The  next  day,  on  the  medical  visit,  there  was  a 
screaming  attack.  His  plight  seemed  not  so  much  simulation 
as  one  of  traumatic  hysteria. 

Again,  after  his  stay  at  the  nerve  hospital,  another  hys- 
terical outburst  was  produced  by  a  hearing  test  with  vestib- 
ular apparatus,  in  the  ear  clinic,  February  6,  191 5.  The 
diagnosis  was  nervous  deafness  with  involvement  of  left  ear. 

The  insomnia  was  successfully  treated  by  sodium  bicar- 
bonate. There  was  a  slight  improvement  in  speech.  In 
March  body  weight  had  improved,  but  there  was  a  marked 
tremor  of  the  right  hand.  In  the  next  few  months  there  was 
a  progressive  improvement  in  general  well-being,  in  speech 
disorder,  and  in  tremor.  The  auditory  disorder  remained 
unchanged.     The  man  now  works  in  his  father's  garden. 

This  case  appears  to  show  a  combination  of  psychic  and 
mechanical  injury.  There  are  severe  hysterical  auditory 
and  speech  disorders.  Although  the  auditory  disorder  is 
of  mechanical  origin,  the  speech  disorder  appears  to  be  of 
psychogenic  nature.  It  is  somewhat  remarkable  that  the 
ear  tests  almost  every  time  produce  hysterical  attacks  in  the 
form  of  convulsive  crying.  Rather  unusual  is  the  general 
cutaneous  hyperalgesia,  more  marked  about  the  ears. 


300  shell-shock:  nature  and  causes 


Shell-shock  (distant,  neither  seen  nor  heard) ;  left 
t3mipanum  ruptured;  semicoma  eight  days:  Cere- 
bellar s3mdrome  and  hemianesthesia.  Recovery, 
nine  months. 


Case  218.  (Pitres  and  Marchand,  November,  1916.) 
A  lieutenant  underw^ent  "  shell-shock  "  either  at  night  or  in 
the  early  morning,  September,  191 5,  the  shell  bursting  at  a 
distance.  He  neither  saw  nor  heard  the  shell,  lost  conscious- 
ness and  was  eight  days  semicomatose,  failing  to  recognize 
his  wife. 

On  recovering  his  senses,  he  could  not  get  about,  as  he 
had  lost  his  memory,  having  to  w^ite  down  his  room  number 
and  be  warned  of  meal  times.  He  was  led  about  like  a  child. 
He  had  a  continuous  headache  on  the  right  side  and  pains  in 
the  occiput  and  along  the  spinal  column,  as  well  as  in  the 
right  leg  as  far  as  the  heel.  These  leg  pains  were  lightning 
pains.  Walking  was  difficult,  staggering,  leaning  to  left. 
Weakness  of  right  arm  and  leg;  right-sided  hemianalgesia. 
Complete  insomnia.  During  November  there  were  frequent 
urgent  desires  to  urinate  day  or  night.  Evacuated  to  the 
oto-rhino-laryngological  center  in  Bordeaux,  December  13,  for 
examination  of  ears.  The  right  ear  was  found  normal,  but 
there  was  a  rupture  of  the  left  tympanum.  There  was  at 
this  time  a  trismus.  The  jaws  were  opened  with  the  dilator 
and  the  man  had  a  syncope  during  this  operation.  The 
question  of  surgical  intervention  for  a  cerebral  lesion  was 
raised,  but  he  was  first  sent  to  the  neurologists  at  Bordeaux. 
There,  December  31,  he  was  found  with  a  facies  of  anguish, 
unstable  gait,  inclination  to  the  left  in  walking ;  no  Romberg- 
ism;  occasional  dizzy  spells.  In  walking,  the  right  foot 
was  pointed  outward  and  on  request  to  direct  it  forward  he 
complained  of  pain  in  the  loins,  reaching  as  far  as  the  scapula. 
Walking  with  eyes  closed,  he  leaned  to  the  left  and  lost  bal- 
ance. With  eyes  open,  no  disorder  of  balance.  With  eyes 
closed,  the  body  leaned  backward.  If  requested  to  go  back, 
he  failed  to  flex  his  legs  to  keep  balance.     If  he  was  asked  to 


SHELL-SHOCK:    NATURE   AND   CAUSES  3OI 

put  a  foot  upon  the  chair  in  front  of  him,  he  immediately 
fell  backwards.  He  could  not  support  his  body  on  the  right 
leg  more  than  a  few  moments.  He  had  difficulty  in  raising 
both  legs  from  the  bed  at  one  time  and  he  could  lift  the  right 
leg  not  so  high  as  the  left.  Movements  of  the  legs  were 
performed  hesitatingly  and  slowly  and  with  greater  diffi- 
culty with  eyes  closed. 

He  could  not  thread  a  needle  and  could  hardly  dress  him- 
self. Eyes  closed,  he  could  with  difficulty  perform  the  finger 
to  nose  test;  eyes  open,  with  much  less  difficulty.  Adiado- 
chokinesis ;  muscular  strength  less  in  right  than  left ;  plantar 
reflexes  absent;  knee-jerks  lively;  hemianalgesia,  right  side. 
Loss  of  deep  and  bony  sensibility  on  right  side  and  diminution 
of  testicular  sensibility.  Retraction  of  visual  field,  right; 
diminution  of  smell  and  loss  of  hearing,  right;  position  sense 
absent  on  this  side;  stereognostic  sense  preserved.  Men- 
tally, memory  was  poor;  he  was  unable  to  read  or  do  mental 
work.  He  slept  little  and  had  bad  battle  dreams.  He  was 
very  impressionable  and  emotional  and  constantly  com- 
plained of  occipital  pain.     He  had  lost  8  kilos  weight. 

He  grew  gradually  better.  In  May  he  could  go  out  alone. 
The  muscular  strength  increased.  The  adiadochokinesis  and 
synergic  disturbances  lessened;  the  hemianesthesia  persisted. 
In  June  there  was  greater  improvement;  in  fact,  there  was 
no  sign  of  disorder  left  except  irregular  sleep. 

We  here  deal  with  a  cerebellar  syndrome  plus  a  hemian- 
esthesia. 


302  SHELL-SHOCK:    NATURE  AND   CAUSES 


Mine  explosion:  Tremors,  mutism,  hemiplegia. 
Tremors  cleared  by  hypnosis.  Mutism  replaced  by 
stuttering.    Persistent  hemiplegia,  probably  organic. 


Case  219.     (Smyly,  April,  1917.) 

A  soldier  was  blown  up  by  a  mine  and  rendered  uncon- 
scious. Upon  recovery  of  consciousness,  the  patient  was 
dumb,  unable  to  work,  very  nervous,  paralyzed  as  to  left 
arm  and  leg.  The  paralysis  improved  so  that  in  the  hospital 
at  home  the  patient  became  able  to  get  about.  However, 
he  threw  his  legs  about  in  an  unusual  fashion.  Several 
months  later  the  patient  was  much  improved. 

Shortly,  there  was  a  relapse.  Transferred  to  a  hospital 
for  chronic  cases,  the  patient  was  unable  to  walk  without 
assistance  on  account  of  complete  paralysis  of  the  leg.  There 
was  insomnia,  a  general  tremor,  bad  stuttering,  and  a  habit 
of  starting  In  terror  at  the  slightest  noise. 

Hypnotic  treatment  was  followed  by  almost  complete 
disappearance  of  the  tremor.  The  patient  began  to  sleep 
six  or  seven  hours  a  night;  nervousness  diminished,  and  the 
stuttering  slowly  improved ;  but  neither  the  paralysis  nor  the 
anesthesia  of  the  left  leg  was  affected  by  suggestion.  The 
leg  remained  cold,  livid,  anesthetic,  and  fiaccldly  paralyzed 
to  the  hip.  A  slight  Improvement  has  followed  upon  fara- 
dization but  the  patient  still  can  walk  only  with  assistance. 

Smyly  regards  this  case  as  probably  not  a  true  case  of  Shell- 
shock,  depending  as  he  states  "  more  on  a  lesion  in  the 
nervous  system  than  in  the  psyche." 


SHELL-SHOCK:    NATURE  AND   CAUSES  303 


Shrapnel buUetWOUND  of  skull:  Unconsciousness 
(three  weeks),  followed  by  agraphia  (three  weeks), 
insomnia  (six  weeks),  amnesia  (sis  to  eight  weeks), 
hemiplegia  (twelve  weeks),  impairment  of  vision 
(twelve  to  sixteen  weeks),  dreams  (seven  months). 
Recovery  save  for  slight  overfatiguability. 


Case  220.     (BiNswANGER,  October,  191 7.) 

A  French  tailor,  aged  22,  of  healthy  stock,  was  wounded  in 
the  left  frontal  bone  In  August,  1914.  The  shrapnel  bullet, 
from  an  unknown  distance,  made  a  penetrative  wound.  The 
man  was  able  to  remember  how  at  the  moment  he  was  injured 
he  felt  a  sort  of  strain  in  his  brain,  felt  his  head  with  his  hand, 
found  he  was  bleeding,  took  out  a  bandage  from  his  kit,  re- 
moved it  from  its  cover  and  without  unfolding  It  put  It  on  his 
head.  At  this  moment  he  fell  unconscious  and  there  was  then 
complete  loss  of  memory  for  three  weeks.  This  patient, 
who  was  Intellectually  keen,  distinguished  exactly  between 
what  he  could  himself  remember  and  what  he  was  told  by  his 
comrades.  One  of  these  had  told  him  that  he  had  cried  out 
indistinctly  that  In  a  matter  of  fifteen  days  he  would  be  well. 
He  estimated  the  Interval  between  his  wound  and  the  loss  of 
consciousness  as  about  five  minutes. 

After  three  weeks,  the  tailor  came  to  and  remembers  that 
the  first  word  he  heard  was  Munich.  Astonished  to  be  in 
Bavaria  he  asked  for  paper  and  pen  to  write  to  his  people, 
but  found  he  could  not  write,  though  still  able  to  dictate  a 
little  to  his  comrades  Besides  agraphia  there  was  hemiplegia 
on  the  right  side,  marked  exhaustion,  rapid  fatlguability  of 
vision,  power  of  concentration  but  slightly  diminished,  and 
apathy  for  his  surroundings;  emotions  normal. 

Three  weeks  later  the  power  to  write  returned;  after  six 
weeks,  sleep;  memory  was  restored  in  from  six  to  eight  weeks; 
the  paralysis  disappeared  in  twelve  weeks;  vision  became 
normal  In  three  or  four  months;  the  dreams  ceased  after 
seven  months.  The  mood  for  the  first  two  months  after  re- 
gaining consciousness  was  slightly  elevated;  for  another  two 
months  slightly  depressed.     The  mood  then  became  normal. 


304  SHELL-SHOCK:    NATURE   AND   CAUSES 

There  was,  then,  in  this  case  complete  recovery  save  for  slight 
overfatiguability  in  a  period  of  seven  months.  There  were 
still  a  few  residuals  of  hemiplegia.  An  operation  in  November, 
19 1 6,  removed  a  shrapnel  ball,  one  centimeter  in  diameter, 
from  a  dural  scar. 

This  is  a  case  of  acute  reaction  psychosis  of  exogenous  origin 
lasting  three  weeks  and  leading  to  complete  recovery  in  an 
after  phase  of  from  four  to  seven  months. 


SHELL-SHOCK:    NATURE   AND   CAUSES  305 


Normal  subject,  wounded  and  thrown  to  ground  by 
shell  explosion:  Recurring  MEMORIES  of  battle 
scene;  persistently  HYPERESTHETIC  healed  shell 
WOUND,  with  pupil  and  pulse  changes  on  pressure 
of  the  scar. 


Case  221.     (Bennati,  October,  191 6.) 

A  lieutenant  of  artillery,  student  (one  of  his  brothers  dead 
of  meningitis) ,  suffered  somewhat  from  diarrhoea  on  the  battle- 
field. He  was,  however,  always  able  to  obtain  the  best  of 
food.  External  conditions  did  not  seriously  interfere  with 
sleep.  In  particular  there  was  no  excessive  dampness  where 
he  was.  He  was  preoccupied  with  having  to  act  as  substitute 
for  the  commandant  of  the  battery.  He  was  not  afflicted  by 
the  thought  of  his  parents  far  away;  their  financial  affairs 
were  entirely  satisfactory. 

This  almost  normal  man  was  wounded  after  a  day  of  in- 
cessant fighting  five  months  after  going  to  the  front.  When 
firing  ceased,  he  withdrew  with  his  soldiers  to  a  trench.  Here 
he  was  followed  by  an  enemy  gas  shell  which  killed  some  and 
wounded  others.  While  outside  the  trench  shifting  mutilated 
soldiers  to  the  rear,  he  was  hit  by  another  shell  of  which  a  chip 
wounded  him  in  the  left  thigh.  He  felt  a  terrible  spanking 
blow  that  threw  him  to  the  ground  and  gave  him  great  pain. 
He  was  carried  on  a  stretcher  to  the  medical  post  across  the 
zone  of  fire;  thence  to  a  field  hospital  and  from  there  to  a 
hospital  further  from  the  front.  He  had  been  for  almost 
seven  hours  in  a  sector  of  the  fighting  line  which  had  been 
almost  continuously  active. 

The  wound  healed  in  less  than  a  week.  But  what  he  had 
seen  and  felt  kept  tormenting  his  mind.  There  remained 
slight  numbness  in  the  wound  where  there  was  to  be  seen  a 
spot  of  pigment,  the  size  of  a  two-cent  coin,  with  somewhat 
obscure  outlines.  The  pain  was  irritated  by  damp  weather, 
in  certain  positions,  and  by  touch,  and  the  pain  on  pressure 
was  reflected  in  the  pupils  and  in  the  pulse. 

No  other  disturbance,  organic  or  functional,  was  found. 


306  SHELL-SHOCK:     NATURE   AND   CAUSES 


Wounds;  operation:  Hysterical  FACIAL  SPASM. 


Case  222.     (Batten,  January,  191 7.) 

A  23-year  old  soldier  was  admitted  to  the  National  Hos- 
pital for  the  Paralyzed  and  Epileptic,  June  18,  1915,  in  the 
following  state:  He  sat  in  bed,  gasping,  with  the  left  side 
of  the  face  set  in  a  strong  tonic  spasm  and  jaws  tightly  set. 
The  contraction  of  the  masseters  was  such  that  his  mouth 
could  not  be  forcibly  opened.  He  himself  could  separate 
his  teeth  for  about  a  half  a  centimeter,  but  the  jaws  came 
together  when  a  spatula  was  brought  for  insertion  and  then 
failed  to  relax.  The  facial  spasm  increased  as  the  jaw  was 
clenched  more  tightly.  The  patient  said  he  was  unable  to 
breathe  excepting  when  sitting  upright,  and  when  put  into 
dorsal  decubitus  he  breathed  violently  through  his  clenched 
teeth  and  held  his  breath  as  long  as  he  could,  "  assuming  a 
purple  tinge,"  as  Dr.  Batten  states,  "  which  was  apt  to  be 
disconcerting  until  one  was  accustomed  to  it."  Faradism 
and  force  permitted  the  removal  of  false  teeth  but  only  to 
the  accompaniment  of  shrieks,  foaming,  and  violent  move- 
ments of  the  arms,  lacrimation,  and  sweating.  During  sleep, 
the  face  was  at  rest.  The  spasm  of  left  face  and  of  jaw  would 
come  on  a  few  seconds  after  waking,  when  an  observer  was 
perceived.  Attempts  to  force  the  mouth  open  invoked  the 
same  procedure  as  before  in  spite  of  the  fact  that  the  patient 
ate  well.     In  a  month  he  was  virtually  normal. 

It  appears  that  May  13,  about  five  weeks  before,  the 
patient  had  been  struck  by  shrapnel  on  the  right  hand,  fore- 
arm, and  shoulder,  and  base  of  the  nose,  while  in  France. 
He  had  been  dazed  but  had  not  lost  consciousness,  and  the 
wounds  had  completely  healed  before  arrival  at  hospital. 
It  was  about  a  week  after  being  wounded  that  the  patient 
was  operated  upon  for  removal  of  shrapnel  from  the  face. 
Upon  recovery  from  the  anesthetic,  the  patient  found  him- 
self unable  to  move  the  right  side  of  the  face.  Unable  to 
remove  his  teeth,  he  had  been  fed  by  rubber  tube. 


shell-shock:  nature  and  causes  307 


Shell-shock :  Hyperesthesia  and  over-reaction. 


Case  223.     (Myers,  March,  1916.) 

A  stretcher-bearer,  19,  who  had  had  18  months'  service 
and  6  months'  service  in  France,  sent  to  Lieut-Col.  Myers 
the  day  after  admission  to  a  base  hospital,  showed  a  remark- 
able condition  of  hyperesthesia  and  over-reaction. 

It  appears  that  four  days  before,  he  had  been  blown  up 
three  times  by  aero  torpedo  mortar  shells  while  attending 
the  wounded.  One  had  blown  him  into  the  air,  another  had 
blown  him  into  a  dug-out,  and  a  third  had  knocked  him  down. 
Two  or  three  hours  later,  having  finished  the  job  of  carrying 
wounded  to  the  dressing  station,  everything  seemed  to  "go 
black  "  in  the  dug-out  where  he  was  resting,  and  from  that 
time  on  he  had  been  shaky.  It  seemed  that  he  had  hardly 
slept  for  several  days  before  he  finally  gave  in. 

There  were  irregular  spasmodic  movements  of  the  head, 
arms  (especially  the  right),  and  legs  (especially  the  left). 
There  were  coarse  tremors  and  incoordination  in  moving  the 
arms.  With  eyes  closed,  he  touched  his  nose  with  uncer- 
tainty. Cotton-wool  touch  on  arms  or  head  provoked  lively 
movements.  "  I  was  always  ticklish,  "  he  explained,  "  but 
never  like  this;  I  can't  stand  it,  Sir."  Pinpricks  produced 
almost  convulsions.  There  was  perspiration,  rigidity  of  legs, 
and  spasm  such  that  knee-jerks  were  unobtainable.  Plantar 
reaction,  flexor.  There  were  also  visual  hallucinations  of 
bursting  shells,  and  these  were  also  heard  when  dozing. 

Improvement  followed  with  rest,  but  about  two  weeks 
later,  on  waking  to  find  himself  being  carried  back  to  his 
tent  to  avoid  a  shower,  he  was  so  terrified  that  a  special  nurse 
became  necessary.  He  was  still  jumpy  the  next  day,  alarmed 
at  footsteps,  and  afflicted  with  headache.  He  improved 
further  in  three  days;  remained  two  months  in  hospital  in 
England,  had  one  month's  leave,  and  then  returned  to  light 
duty. 


308  SHELL-SHOCK:    NATURE   AND   CAUSES 


Shell-shock ;  thrown  against  wall ;  comrades  killed ; 
no  visible  trauma,  or  loss  of  consciousness:  Per- 
sistent TREMORS,  augmented  in  intentional  move- 
ments; CRISES  of  agitation  following  noise  or 
emotion. 


Case  224.     (Meige,  February,  19 16.) 

A  corporal  (an  expert  gunner)  and  his  squad  had  just  entered 
a  mine  shaft  on  Nouvron  Plateau,  January  13,  1915,  when  a 
shell,  bursting  above  them,  threw  him  violently  against  the 
wall  and  killed  or  wounded  several  of  his  comrades.  The 
corporal  himself  was  not  wounded,  nor  is  it  clear  that  con- 
sciousness was  lost  The  man  lay  waiting  on  the  ground  for 
some  time  until  a  communication  trench  could  be  finished 
and  he  could  be  evacuated  without  much  danger  from  the 
mine  shaft.  He  had  already  begun  to  tremble,  and  trembled 
still  more  while  going  back  in  the  trench. 

He  carried  on  there  for  a  fortnight,  always  trembling,  but 
not  eating  and  no  longer  able  to  handle  a  gun.  He  was  evacu- 
ated a  month  later  and  sent  successively  to  Villers-Cotterets, 
to  Meaux,  to  Courneuve  (a  month),  again  to  Meaux,  and 
finally  to  the  neurological  center  at  Villers-Cotterets,  where 
he  remained  for  two  months  (April  13  to  June  15,  1915). 
Here  he  was  given  the  diagnosis  of  hysterical  chorea  by  Guil- 
lain,  and  showed  lively  knee-jerks  and  Achilles  jerks  and  great 
emotionality.  The  tremors  were  greatly  increased  when  the 
cannon  grew  loud  or  bombs  burst  nearby.  Lumbar  punc- 
ture here  showed  a  perfectly  normal  spinal  fluid.  He  was 
then  sent  to  the  Salpetriere,  June  19,  191 5,  and  was  evacuated 
July  13  to  a  civil  hospital  until  September  24,  whence  he  was 
sent  for  convalescence  to  his  home  village,  October  6  to 
December  15,  from  which  he  was  returned  to  the  Salpetriere. 

Throughout  these  transfers  there  had  been  no  change  what- 
ever in  his  status.  For  almost  a  year,  as  the  result  of  a  shell 
explosion,  he  had  been  trembling  in  precisely  the  same  way. 
All  four  extremities  trembled  equally,  unless  the  right  arm 
and  the  left  leg  might  be  thought  to  tremble  a  bit  more.     The 


shell-shock:  nature  and  causes  309 

tremor  was  equally  pronounced  in  dorsal  decubitus  as  in  the 
sitting  or  upright  postures,  but  ceased  during  sleep.  The 
tremors  were  worse  in  the  evening  and  it  was  hard  for  the  man 
to  get  to  sleep.  The  eyelids  and  tongue  showed  a  few  irregu- 
lar, jerking  movements,  not  synchronous  with  the  tremor  of 
the  extremities.  The  head  showed  few  tremors.  The  patient 
was  able  to  diminish  the  trembling  of  the  arms  somewhat  by 
keeping  the  elbows  flexed  at  a  right  angle  and  held  firmly  to 
his  body.  If  the  tremor  of  the  legs  got  more  energetic,  the 
patient  would  get  up  and  take  a  few  steps.  Any  movement, 
such  as  laying  hold  of  an  object,  carrying  a  spoon  or  a  glass  to 
the  mouth,  led  to  an  exaggeration  of  the  tremors  in  such  wise 
that  the  tremor  of  multiple  sclerosis  in  its  most  extreme  form 
was  recalled.  It  was  very  hard  for  the  man  to  eat.  If  the 
eyes  were  closed,  the  tremors  grew  more  marked.  The 
emotion  caused  by  sudden  noise  or  sharp  command  or  memory 
of  his  trench  life  caused  motor  crises,  with  coarse,  generalized 
movements,  and  even  loss  of  balance.  This  agitation  grew 
gradually  less  marked,  but  the  tremors  persisted.  An  at- 
tempt to  test  reflexes  led  to  violent  generalized  contractions. 
There  was  no  sensory  disorder.  The  pulse  was  variable;  at 
rest  it  stood  at  60 ;  if  a  table  near  by  was  struck  suddenly,  the 
pulse  would  go  up  to  120. 


3IO  SHELL-SHOCK:    NATURE  AND   CAUSES 


Sharp  gunfire:     TREMORS;     TREMOPHOBIA. 

A  patient's  (an  artist)  description  of  his  feelings. 


Case  225.     (Meige,  February,  1916.) 

One  of  Meige's  victims  of  shell-shock  tremors  was  an 
artist.  He  stood  the  hardest  sort  of  trench  life  for  many 
months  without  disorder.  Under  particularly  sharp  fire, 
"the  machine  went  off  the  track,"  as  the  artist  said,  and  he 
began  to  tremble.  Both  arms  and  head  trembled,  but  espe- 
cially the  head,  which  was  subject  to  small  sidewise  oscilla- 
tions, variable  in  degree,  and  almost  permanent,  —  a  sort  of 
vibration  which  the  patient  could  diminish  somewhat  by 
stiffening  his  neck  muscles.  His  manual  tremor  was  not 
exaggerated  by  voluntary  movements.  Superficially  he  re- 
sembled a  Parkinsonian  case.  He  presented  a  curious 
appearance  of  combined  vibrations  and  stiffness. 

There  was  no  doubt  that  this  tremor  had  an  emotional 
origin.  In  fact,  the  psychopathic  status  of  the  patient  was 
described  by  the  artist  himself.  "My  nervous  state,  which 
I  thought  ought  to  last  not  more  than  a  fortnight,  still  per- 
sists more  than  three,  or  almost  four,  months  after  being 
evacuated,  although  the  trembling  is  a  little  less.  I  am 
calmer  and  palpitate  less,  and  my  hands  perspire  less  when 
I  am  emotional  or  making  an  effort.  At  first,  the  slightest 
shock  immediately  ran  through  me,  followed  by  an  uncon- 
trollable trembling.  Now  there  is  an  appreciable  delay  be- 
tween the  shock  and  the  trembling;  I  can  control  it  for  a 
few  seconds  but  not  longer.  The  subway  gate  noises,  a 
flaring  light,  a  locomotive  whistle,  the  barking  of  a  dog,  or 
some  boyish  prank  is  enough  to  set  off  the  trembling;  going 
to  the  theater,  listening  to  music,  reading  a  poem,  or  being 
present  at  a  religious  ceremony,  acts  the  same  way.  Re- 
cently when  a  flag  was  being  raised  at  the  Invalides,  I  thought 
at  first  that  I  was  going  to  be  cured  by  so  moving  a  spectacle, 
but  then  I  suddenly  began  to  tremble  so  violently  that  I 
had  to  cry  out,  and  I  had  to  sit  down,  weeping  like  a  child. 
Sometimes  the  trembling  comes  on  suddenly  without  any 


shell-shock:  nature  and  causes  311 

cause.  I  went  to  a  novelty  shop  to  do  some  errands  with 
my  wife.  The  crowd,  the  lights,  the  rustling  of  the  silk, 
the  colors  of  the  goods  —  everything  was  a  delight  to  me  to 
look  upon,  —  a  contrast  to  our  trench  misery.  I  was  happy 
and  chatted  merrily,  like  a  schoolboy  on  a  vacation.  All  of 
a  sudden  I  felt  that  my  strength  was  leaving  me.  I  stopped 
talking;  I  felt  a  bad  sensation  in  my  back;  I  felt  my  cheeks 
hollowing  in.  I  began  to  stare,  and  the  trembling  came  on 
again,  together  with  a  great  feeling  of  discomfort.  If  I  can 
lean  against  something,  sit  down,  or  better,  lie  down,  the 
trembling  gets  better  and  pretty  soon  stops.  There  are  three 
conditions  in  which  I  feel  well:  first,  upon  waking  after  11 
or  12  hours'  sleep;  next,  after  a  meal,  especially  if  it  is  a 
good  one;  and  lastly,  and  above  all,  when  I  get  the  electric 
douche.  Then,  as  if  by  magic,  my  ideas  get  clear,  cheerful, 
and  regain  color;  I  feel  myself  again.  That  lasts  for  an  hour 
or  so;   then  I  relapse  Into  my  sad  state." 

As  to  the  tremophobia,  this  patient  says  "In  the  tramway 
or  in  the  subway,  I  perceive  that  people  are  looking  at  me, 
and  that  gives  me  a  terrible  feeling.  I  feel  that  I  am  in- 
spiring pity.  Some  excellent  woman  offers  me  her  seat.  I 
am  deeply  touched ;  but  if  they  look  at  me  and  say  nothing, 
what  are  they  thinking  of  me?  This  anxiety  makes  me 
suffer  a  good  deal.  If  I  am  able  to  speak  it  is  less  painful 
to  me,  for  then  i  is  obvious  that,  despite  my  trembling,  I 
am  not  a  coward.     What  a  sad  situation  this  is!" 

Meige  remarks  that  therapeutics  is  not  especially  suc- 
cessful in  these  cases  of  tremor.  Sedative  drugs,  hyoscya- 
min,  hyoscin,  duboisin,  and  scopolamin,  do  not  last  long 
and  should  be  used  cautiously.  Static  lectricity  works  well 
in  some  cases.     Rest  isolation,  and  calm. 

As  for  the  military  prognosis,  a  period  of  observation  of 
some  three  to  four  months  may  be  necessary  to  learn  the 
nature  of  the  tremor.  If  the  tremor  then  fails  to  alter,  a 
convalescent  leave  for  one  or  wo  months  may  be  given. 
The  patient  should  then  be  re-observed  hy  the  same  physician. 
Upon  persistence  of  tremor,  temporary  invaliding.  Tremors 
may  be  wittingly  cultivated  for  medicolegal  purposes  (Bris- 
saud's  sinistrosis.) 


312  SHELL-SHOCK:    NATURE   AND   CAUSES 


Letters  of  a  German  soldier  about  his  shell-shock. 


Case  226.     (Gaupp,  April,  1915.) 

A  volunteer,  21,  who  had  been  in  civil  life  a  lackey,  wrote 
as  follows  upon  arrival  in  Gaupp's  clinic: 

"On  account  of  our  privations  and  the  various  ter- 
rible scenes  that  you  have  to  see,  my  nerves  went 
back  on  me.  Like  the  rest  of  the  front,  we  too  had  to 
suffer  terribly  heavy  artillery  fire  from  December  20  on- 
wards. December  29  at  eight  o'clock  in  the  evening, 
when  I  was  about  to  mount  guard  at  the  camp,  I  was 
thrown  down  by  a  shell  that  unexpectedly  struck  near 
me  across  the  earth  pushed  out  into  a  trench.  I  ran 
at  once  to  cover  as  some  more  shots  followed  directly. 
I  couldn't  be  made  to  do  anything  on  the  thirtieth 
nor  can  I  very  clearly  remember  the  events  of  that 
day.  There  was  a  terrific  cannonade  again,  then  cries 
of  the  wounded  and  the  sight  of  the  dead,  etc.  I  was 
told  afterwards  that  I  fell  down,  cried,  struck  about 
me,  and  remained  lying,  dazed.  The  first  that  I  can 
remember  was  that  I  was  lying  on  a  floor.  I  was  then 
carried  into  another  house,  into  a  better  room.  Then 
I  regained  consciousness  and  could  hear  again  after 
the  noise  in  the  ears  had  stopped,  but  I  could  not  talk 
or  walk.  I  was  unconscious  for  two  days.  I  got  into 
the  hospital  train  at  R.  the  next  day  but  had  to  be 
carried  in  as  I  could  not  walk.  Travelling  in  the  train 
made  me  quite  foolish  in  my  head  and  gave  me  bad 
headaches;   I  could  not  form  any  clear  thoughts." 

It  seems  that  this  volunteer  had  not  been  quite  up  to  the 
hardships  of  the  war  from  the  beginning;  always  a  weakling, 
he  had  to  be  spared  on  the  marches.  In  fact,  he  had  been  re- 
fused by  the  army  at  the  first  examination  as  unfit.  He  had 
been  a  nervous,  tender,  somewhat  anxious  fellow  since  child- 
hood. 

At  the  clinic  there  was  an  astasia  and  an  abasia  without  any 
signs  of  organic  disease.  The  striking  feature  was  mutism. 
He  could  understand  things  spoken  and  written,  but  he  was 
entirely  mute,  nodding  and  shaking  his  head  properly  for 
afhrmatives  and  negatives.     He  carried  with  him  a  few  slips 


SHELL-SHOCK:    NATURE   AND    CAUSES  313 

of  paper  with  written  requests,  like:  "  Please,  can  I  have  salt; 
otherwise  I  can't  eat  the  soup;  "  "Are  we  going  to  ride 
farther,  I  have  such  a  bad  headache.  The  doctor  must  not 
come.  The  one  who  wanted  to  shoot  me  if  I  couldn't  speak. 
They  are  all  bad." 

Treatment  by  suggestion  (laryngeal  faradization,  lively 
verbal  suggestion  to  pronounce  single  vowels,  syllables,  and 
whole  words  and  sentences  with  enunciation  of  them)  removed 
the  mutism  in  a  few  days.  At  first  the  man's  speech  was  low 
and  somewhat  retarded,  but  later  it  became  entirely  normal. 
Within  ten  days  the  abasia  cleared  up  and  the  patient  became 
lively  and  cheerful.  He  was  depressed  on  finding  that  he  had 
lice,  but  after  losing  them  became  happy  and  childlike  again. 

February  i,  however,  on  learning  that  he  would  be  able  to 
do  garrison  duty  again,  he  took  the  news  very  soberly,  and 
grew  more  quiet,  trembled  and  seemed  anxious. 

February  7,  he  was  sent  to  the  garrison,  increasingly  ex- 
cited. His  own  account  of  it  in  a  letter  written  to  a  hospital 
nurse,  runs  as  follows: 

"As  you  will  see,  I  did  not  reach  Dn.  but  only  got 
as  far  as  here  [Another  hospital].  I  will  tell  you  how 
it  happened.  Probably  I  ought  to  have  remained  in 
Tubingen  for  a  while  longer  and  perhaps  then  nothing 
would  have  happened  to  me.  You  will  remember  that 
I  was  more  nervous  and  excited  the  last  days  than  I 
had  been  before,  and  the  cause  was  also  known  to  you. 
I  wanted  to  get  home  in  some  way  and  so  I  pretended 
to  be  as  well  as  possible.  That  crying  attack,  or  what- 
ever it  was  [an  outcry  in  a  frightful  dream]  had  not 
been  thought  of  by  the  physician  any  further,  you  know, 
and  so  I  didn't  think  anything  about  it  either.  Then 
the  head  doctor  asked  me  once  if  I  had  any  trouble  left. 
Well,  I  spoke  out  everything  I  had  to  say,  but  no  further 
attention  was  paid  to  that  either.  Then  when  I  took  a 
walk  and  after  walking  slowly  two  hours  could  hardly 
stand,  was  trembling  all  over  and  had  a  high  pulse  and 
also  a  violent  acute  pain  in  the  region  of  the  heart,  that 
wasn't  of  any  importance  either.  Well,  then  I  just  got 
better  from  day  to  day  and  so  I  got  what  I  wanted  only 
too  easily  because  they  wanted  the  space  and  I  certainly 
would  have  gone  home  and  not  to  Dn.  as  I  should  have. 
[His  reserve  battalion  was  at  Dn.]     I  got  into  the  wrong 


314  SHELL-SHOCK:    NATURE   AND   CAUSES 

train  at  St.  so  as  to  go  home.  I  kept  saying  to  myself, 
'You  can't  do  that,  it  will  be  punished.'  Nevertheless 
I  couldn't  act  any  other  way  because  I  was  really  sick 
from  longing  for  home." 

Here  he  described  an  episode  in  a  comrade  who  had  lain 
beside  him  in  the  clinic,  had  gone  off  with  him  and  had 
a  hysterical  excitement  in  Heidelberg  so  that  he  had  to  be 
detrained. 

"I  was  so  awfully  sorry  to  see  him  so  miserable.  I 
began  to  cry  and  was  startled  by  every  train  coming  from 
the  opposite  direction  and  by  every  loud  noise.  I  was 
stared  at  by  everybody  in  Frankfort  and  I  could  only 
cry  more.  Then  a  soldier  scolded  me  because  I  was 
running  senselessly  up  and  down.  Finally  I  got  into 
the  Leipzig  train.  Another  guard  questioned  me. 
Everything  then  got  more  and  more  confused  in  me;  I 
heard  my  mother  call;  then  I  heard  shooting  again; 
and  finally  I  was  entirely  confused.  I  came  to  my 
senses  in  a  room  in  the  station  toward  evening,  and  was 
frightened  again  at  a  loud  noise  somewhere  or  a  passing 
train.  Then  I  was  told  what  I  had  done  in  the  train. 
I  had  cried  out  and  raved,  tried  to  get  out  of  the  car, 
called  for  my  father  and  mother,  wanted  to  go  home, 
imitated  shooting;  allowed  myself  to  be  calmed  a  little, 
but  began  to  shout  again  at  every  loud  noise.  When  I 
was  out  of  the  train  I  bit  a  soldier  and  tore  his  whole  coat 
open,  so  then  I  was  carried  to  the  hospital  here  in  an 
auto.  Up  to  this  time  I  have  been  able  to  calm  myself 
very  well.  The  physician  said  that  it  was  quite  natural 
that  I  should  not  have  very  strong  nerves  yet.  I  must 
have  beaten  about  and  got  knocked  against  things  a 
good  deal.  There  are  bruises  on  my  head  and  I  am 
covered  with  black-and-blue  spots." 


SHELL-SHOCK:    NATURE  AND   CAUSES  315 


A  British  soldier's  accoiint  of  his  shell-shock. 


Case  227.     (Batten,  January,  1916.) 

A  British  soldier,  22  years,  who  went  out  to  France  In 
November,  1914,  remained  well  until  March  12,  191 5,  when 
after  shell  explosion,  he  became  unconscious  for  half  an  hour, 
and  on  recovery  found  he  was  deaf  and  dumb.  He  was  able 
to  think  of  words  but  could  not  say  them.  He  remained 
dazed  and  frightened  for  a  time,  and  still  wakes  up  with  a 
start  at  night. 

He  was  admitted  to  the  National  Hospital  for  the  Paralyzed 
and  Epileptic,  March  25,  191 5,  and  on  March  27  recovered 
his  speech  suddenly  and  spontaneously.  By  March  29 
he  had  completely  recovered  and  talked  well.  Dr.  Batten 
remarks  "  how  perfect  the  memory  may  be  up  to  the  time  of 
concussion,  and  how  complete  the  mechanism  is  for  express- 
ing the  ideas  in  written  words  when  that  for  spoken  words 
is  abolished";  which  may  be  seen  from  the  patient's  own 
account,  as  follows: 

I  went  out  to  France  on  the  3/11/14  and  I  was  two 
days  at  Le  Havre  and  then  we  went  on  to  our  ist  Batt. 
When  we  arrived  at  our  destination  the  regiment  was  in 
the  trenches  so  we  had  to  go  In.  It  was  snowing  hard 
and  I  felt  it  very  cold.  This  was  at  Givenchy.  We 
were  relieved  the  following  night  and  we  went  back 
for  a  rest.  The  next  place  we  went  to  was  just  opposite 
Neuve  Chapelle  on  the  La  Bassee  Road  and  it  was 
awful,  the  trenches  were  up  to  the  knees  in  mud  and 
water.  The  first  night  was  very  quiet,  but  the  follow- 
ing morning  about  9  p.m.  the  Germans  started  shelling 
and  continued  all  day;  the  next  was  the  same,  but  about 
I  o'clock  the  Germans  were  seen  to  be  coming  up  in 
masses.  They  got  to  within  a  distance  of  about  twenty- 
five  yards,  then  they  turned.  They  commenced  shell- 
ing us  again  and  they  had  another  try  about  three 
o'clock  but  they  did  not  get  far.  One  of  the  men  on  my 
left  had  the  half  of  his  face  blown  away  and  we  had 
about  ninety-two  killed  and  wounded.  We  got  re- 
lieved after  being  In  five  days,  then  we  went  back  for 
three  days'  rest.     The  next  place  we  went  to  was  Rue 


3i6  shell-shock:   nature  and  causes 

de  t'Epinette  and  we  had  an  awful  time  there  just  be- 
fore Christmas.  We  went  into  the  trenches  and  we 
were  up  to  our  middle  in  water  and  in  some  places  it 
would  have  taken  you  over  the  head.  We  were  in  these 
trenches  for  twenty-four  hours.  There  was  nothing 
unusual  happened  and  we  got  relieved  by  the  Royal 
North  Lanes. ;  but  we  did  not  get  far  away;  we  had  just 
got  into  our  billets  and  were  making  some  tea  when 
the  fall-in  went  and  we  were  told  that  the  Germans 
had  broken  through  the  North  Lanes.  We  went  away 
without  any  great-coats,  and  into  the  trenches  we  went 
for  other  seventy-two  hours,  and  if  the  Germans  had 
attacked  again  we  could  not  have  fired  a  shot  as  we 
were  hardly  able  to  stand  for  the  cold  and  with  the  wet 
kilts  on  our  legs  it  was  awful.  We  got  nothing  to  eat 
except  three  biscuits  that  some  of  the  men  went  out 
and  got.  When  we  came  out  of  the  trenches  on  Christ- 
mas Eve  we  looked  all  like  old  men  and  a  lot  of  them  had 
to  be  carried.  We  went  back  for  a  rest  to  (Nervaille?) 
about  thirty  kilometers  from  the  firing  line  for  a  month. 
When  we  came  back  again  we  went  to  La  Bassee  and  had 
a  pretty  hot  time  there.  The  next  place  we  were  at  was 
at  that  big  fight  at  Neuve  Chapelle  when  472  guns 
bombarded  the  German  trench  for  thirty-five  minutes. 
At  about  7  p.m.  the  word  was  passed  along  that  we  were 
to  charge  the  German  trench  in  front  supported  by 
the  City  of  London  Territorials,  We  got  the  trench 
all  right  and  I  got  orders  about  4  p.m.  to  go  back  to  our 
owTi  trench  and  bring  along  the  belt-filling  machine 
belonging  to  the  machine  gun.  There  was  not  a  proper 
communication  trench,  there  was  a  small  dry  ditch  that 
ran  out  in  the  direction  of  the  trench  we  had  taken  for 
a  distance  of  150  yards,  the  other  100  yards  you  had  to 
come  across  the  open.  We  got  into  our  trench  all 
right,  and  I  got  this  box  on  my  back  and  started  back 
to  the  trench.  I  was  just  stepping  out  of  the  trench 
when  a  shell  burst  just  over  my  head  and  I  went  down. 
When  I  came  to  my  senses  I  was  lying  in  our  support 
trench  where  I  had  been  carried  by  two  of  the  men  of 
the  4th  Black  Watch.  One  of  them  said  something  but 
I  could  not  hear  him  and  I  tried  to  tell  him  so,  then  I 
discovered  that  I  could  not  speak. 


CONTRACTURE,  5  M.;  CURE  2  D. 


PSEUDOCOXALGIA,  4  M. 


PSEUDOCOX.\LGL^,  CAMPTOCORML\,  I  Y. 


LEG  DISORDER  (SCIATIC),  5  M. 
CURE  IN  A  FEW  DAYS 


RESULTS  OF  TREATMENT  — HYSTERIC.\L  LEG  DISORDERS 
(ROUSSY-LHERMITTE) 


SHELL-SHOCK:    NATURE   AND   CAUSES  317 


Shell-shock  by  windage:  Hysterical  crural  mono- 
plegia, of  gradual  development  beginning  four  days 
after  accident.     Recovery  by  suggestion. 


Case  228.     (Leri,  February,  191 5.) 

A  number  of  chasseurs  were  doing  the  "  tortoise-shell  " 
under  bombardment,  when  the  last  chasseur  in  the  line  was 
blown  forward  above  his  comrades  by  a  shell  bursting  about 
a  meter  behind  him.  He  was  projected  some  four  or  five 
meters,  got  up,  walked  four  or  five  kilometers,  found  an  auto- 
mobile, and  was  carried  to  Nancy.  He  passed,  according  to 
his  story,  red  urine  three  or  four  times.  He  was  six  days  at 
Nancy,  where  a  slight  abrasion  of  the  side  was  treated.  He 
began  to  feel  heavy  in  his  left  leg  on  the  fourth  day.  At 
Vendome,  the  paralysis  got  worse,  and  by  November  17 
he  had  apparently  a  complete  paralysis  of  the  left  lower 
extremity,  called  "  spinal  contusion."  He  walked  upon  two 
canes,  dragging  left  leg  behind  and  had  to  be  carried  upstairs 
on  a  stretcher.  The  reflexes  were  normal  except  that  there 
might  have  been  a  very  slight  excess  of  the  left  knee-jerk. 
There  was  a  slight  hypesthesia  of  the  left  leg,  sharply  limited 
above. 

These  phenomena  were  strikingly  modified,  at  a  single 
sitting,  by  verbal  suggestion  and  faradism,  but  the  man  was 
one  of  those  with  mauvaise  volonte.  He  did  not  want  to  get 
well  so  quickly,  so  that  his  complete  cure  was  delayed  a 
while. 


31 8  SHELL-SHOCK:    NATURE   AND   CAUSES 


NATURE  OF  SHELL-SHOCK :  At  the  nerve  cUnic 
the  patient  presents,  e.g.,  sundry  CONTRACTURES, 
of  such  a  nature  that  they  may  be  caused  to  DISAP- 
PEAR BY  SUGGESTION,  e.g.,  by  mental  influences 
during  recovery  from  chloroform  narcosis  (note 
battle-dreams).  PAINS  and  ANESTHESD^S  dis- 
appear PARI  PASSU  with  the  contractures.  The 
history  is  of  shell  explosion  so  near  as  to  bum 
patient's  clothing,  fall  with  nosebleed,  eight  hours 
unconsciousness,  crural  monoplegia  with  anesthe- 
sia (crawled  3  meters,  however). 


Case  229.     (BiNSWANGER,  July,  1915.) 

The  treatment  of  a  German  private,  22,  for  contracture  of 
the  left  leg  and  other  phenomena,  culminated  in  narcosis. 
Binswanger  lays  stress  upon  the  mental  influence  to  be 
exerted  upon  the  patient  at  the  conclusion  of  narcosis,  at  the 
moment  in  which  the  patient  is  particularly  accessible  to 
verbal  suggestion.  Treatment  (see  diagnostic  details  below) 
was  carried  out  as  follows: 

After  a  few  days  of  essentially  suggestive  treatment  with 
continued  attempts  at  passive  movements  of  the  contracted 
joints  (knee,  ankle,  toe),  with  steady  concentration  of  the 
patient's  attention  upon  the  joints,  a  slight  mobility  in  the 
toe  joint  on  passive  movement  was  obtained. 

After  a  few  more  days,  the  ankle  became  passively  mobile 
to  some  degree;  the  patient  exerted  a  certain  resistance  to 
passive  flexion  of  toes  and  ankle.  A  week  later,  reflex  con- 
tractions of  the  toes  could  be  evoked  by  deep  pin-prick. 
There  had  been  an  analgesia  of  both  lower  thighs  and  of  the 
soles  of  the  feet,  and  this  analgesia  remained  unchanged. 
At  this  point,  the  subjective  complaints  of  the  patient, 
namely,  noises  in  the  head,  especially  in  the  left  ear,  and  other 
cephalic  sensations,  tended  to  disappear  and  the  patient 
felt  subjectively  better;  yet  there  was  still  an  intolerable 
itching  of  the  head  and  spine. 


SHELL-SHOCK:    NATURE  AND   CAUSES  319 

A  month  after  the  admission  of  the  patient  to  the  nerve 
hospital  of  the  psychiatric  cHnic  in  Jena,  there  had  been  no 
essential  change  in  the  immobility  and  contracture  in  ex- 
tension in  the  left  leg.  Accordingly,  with  the  permission 
of  the  patient,  he  was  placed  in  deep  chloroform  narcosis,  and 
the  knee-joint  was  bent  at  a  right  angle  and  fixed  in  approxi- 
mately that  position  with  a  bandage.  This  experiment 
failed  because,  while  the  patient  was  waking  out  of  his  nar- 
cosis, the  leg  slipped  back  into  extension,  breaking  the  band- 
age. Accordingly,  deeper  narcosis  was  undertaken,  and  the 
leg  fixed  at  a  right  angle  in  a  plaster  cast. 

While  the  patient  was  coming  out  of  narcosis,  it  was 
evident  that  he  had  been  dreaming  of  battle  scenes.  In 
fact,  Binswanger  remarks  that  these  dream  pictures  and  the 
words  spoken  while  going  under  and  coming  out  of  narcosis, 
are  curiously  demonstrative  of  "  sympathy  with  the  enemy,'" 
for  while  waking  out  of  narcosis,  he  cried:  "  Dost  see,  dost 
see  the  enemy  there?  Has  he  a  father  and  mother?  Has 
he  a  wife?  I'll  not  kill  him."  At  the  same  time,  he  cried 
hard  and  continually  made  trigger-movements  with  his  right 
forefinger.*  In  point  of  fact,  throughout  his  waking  treat- 
ment, no  one  was  able  to  learn  what  was  going  on  in  his  mind, 
his  sleep  was  good  and  deep,  and  his  emotional  state  was 
entirely  quiet  and  patient. 

As  the  patient  was  coming  out  of  chloroform  and  regaining 
consciousness  of  his  surroundings,  he  was  repeatedly  and 
persistently  assured  that  the  bending  of  his  leg  was  now 
accomplished  and  the  cramp  removed.  All  that  he  would 
now  have  to  do  was  to  get  back  the  strength  of  his  leg. 

During  the  next  few  days  he  complained  of  violent  pains 
in  his  left  knee-joint  and  in  the  ankle-joint,  but  he  remained 
in  good  spirits  and  full  of  confidence.  Accordingly,  in  five 
days  the  plaster  was  removed  and  the  contracture  in  the 
knee-joint  was  found  to  be  completely  absent;  the  knee  was 
easily  movable.  The  ankle-joint  was  but  slightly  movable. 
He  could  accomplish  slight  active  flexion  of  the  knee-joint 

*  Compare  sentiments  of  a  Russian  in  narcosis  (Case  319,. 
Arinstein.)     See  also  Case  181  (Steiner). 


320  SHELL-SHOCK:    NATURE  AND   CAUSES 

while  lying  in  bed,  and  the  toe-joint  had  already,  before  the 
narcosis,  been  both  actively  and  passively  mobile.  After  a 
few  days,  exercises  in  walking  were  begun.  The  patient  had 
a  little  difficulty  with  his  left  knee-joint  in  walking,  walking 
in  fact  as  if  with  knock-knee.  The  foot  was  not  well  raised 
from  the  ground  on  account  of  the  persistent  stiffness  of  the 
ankle-joint.  Walking,  however,  improved  daily.  He  walked 
for  three  hours,  resting  at  intervals. 

A  sensory  examination  showed  that  the  upper  limit  of  the 
analgesia  had  come  down  five  centimeters  from  its  former 
level,  now  occupying  the  left  foot  and  leg  up  to  the  junction 
of  the  lower  with  the  middle  third.  There  was  now  a  zone 
of  anesthesia  interposed  between  the  normal  skin  of  the  upper 
thigh  and  the  anesthetic-and-analgesic  skin  of  the  lower 
thigh  and  leg.  Upon  the  posterior  aspect  of  the  leg,  the 
analgesia  and  anesthesia  had  disappeared  to  a  point  at  about 
the  middle  of  the  upper  thigh. 

About  five  weeks  after  the  narcotic  experiment,  the  ex- 
tended left  leg  could  be  actively  raised  while  lying  in  bed, 
up  to  the  full  extent,  with  slight  tremors.  The  patient 
described  himself  as  fatigued  by  the  active  movements  of  this 
leg.  The  ankle-joint  remained  less  effective.  There  was 
still  a  trace  of  resistance  to  passive  movements.  Although 
the  passive  movements  of  the  toes  were  normal,  active  move- 
ments of  these  were  weak  and  hard  to  execute.  There  was 
still  a  trace  of  difficulty  at  the  knee  in  walking  and  the  gait 
was  awkward,  trepidant,  precipitate.  He  could  get  about 
without  a  cane,  however.  If  unobserved,  his  posture  was 
more  certain  and  free.  If  he  exerted  himself  hard,  severe 
parietal  headache  on  the  right  side  would  develop. 

It  was  then  proposed  to  the  patient  that  another  narcosis 
would  rid  him  of  the  stiffness  in  his  ankle-joint.  He  feared 
narcosis  and  was  told  that  regular  and  energetic  voluntary 
movements  would  also  rid  him  of  the  stiffness.  These  will 
exercises  consisted  in  his  directing  his  whole  attention  to  his 
left  ankle-joint  until  he  felt  it.  Then  he  was  given  the 
command:  "  Let  go  the  joint" — whereupon  he  would  take 
his  attention  away  from  the  ankle-joint  at  once.  In  this 
way,  he  was  told,  his  will  would  make  the  ankle-joint  mobile. 


SHELL-SHOCK:    NATURE  AND   CAUSES  32 1 

Meantime  he  was  given  twice  daily  a  gram  of  bromophen- 
acetine  for  liis  parietal  headache. 

The  result  was  a  rapid  recovery.  There  were  still  a  few 
traces  of  difficulty  at  date  of  report.  The  zone  of  sensory 
loss  had  retreated  to  the  ankle,  with  a  cuiT-like  zone  of  hypal- 
gesia  above  the  definite  zone  of  analgesia  and  anesthesia. 

As  to  the  previous  nature  of  this  case,  although  there  was 
neuropathic  heredity  on  the  mother's  side,  there  had  been  no 
sign  of  any  individual  neuropathic  disposition.  He  had  been 
a  volunteer  since  191 1  in  a  guard  regiment  of  infantry.  His 
military  training  had  been  well  borne;  in  the  war  he  had 
fought  through  20  battles.  On  November  11,  1914,  in  a 
storming  attack,  he  had  had  his  breeches  burned  from  the 
effects  of  a  shell.  He  had  fallen,  unconscious;  the  uncon- 
sciousness lasted  about  eight  hours.  He  found  on  awaking 
that  he  had  had  nosebleed.  When  he  wanted  to  get  up,  he 
found  that  his  left  leg  was  completely  paralyzed  and  insen- 
sible ;  in  fact,  he  thought  it  had  been  cut  away.  He  crawled 
for  about  three  meters  to  a  trench  in  which  there  were  several 
wounded.  In  the  evening  he  was  taken  by  automobile  to  a 
field  hospital,  and  on  the  17th  was  removed  to  a  reserve 
hospital  at  Erfurt.  Thence  he  was  transferred  to  the  Jena 
Hospital,  January  25,  1915. 

A  strongly  built  man,  with  many  reflexes  increased  and  a 
lively  dermatographia.  The  reflexes  of  the  left,  or  contrac- 
tured,  leg  were  lacking;  the  mastoid  processes  were  painful, 
and  the  occiput  and  temples  were  painful  to  percussion.  The 
spinous  processes  of  the  vertebral  column  in  the  lumbar  re- 
gion were  painful.  The  other  phenomena  have  been  suffi- 
ciently indicated  above.  The  head  sensations  were  peculiar; 
there  were  no  pains  but  a  peculiar  itching.  Contraction  of 
the  fingers  of  the  left  hand  was  painful.  There  was  a  feeling 
as  if  there  were  lice  under  the  skin  in  the  left  upper  thigh. 
There  was  itching  in  the  nose,  which  the  patient  described 
as  due  to  the  sulphur  "  out  there,"  meaning  shell  gases. 
Sleep  and  appetite  were  good.  Memory  was  imperfect:  he 
could  no  longer  remember  the  names  of  the  battles,  and  of 
late  had  had  to  count  on  his  fingers  to  find  out  how  much 
was  2  times  2.     As  to  the  curious  parietal  headache,  con- 


322  SHELL-SHOCK:     NATURE   AND   CAUSES 

tralateral  to  the  contractured  leg,  BInswanger  inquires 
whether  we  may  not  here  have  to  do  with  locaHzed  vascular 
phenomena  of  the  brain  part  which  might  conceivably  be 
related  with  the  innervation  of  the  leg.  Binswanger  remarks 
that  if  the  plaster  cast  be  left  on  too  long,  it  may  happen  that 
hysterical  contracture  will  take  place  in  the  new  position. 

As  to  the  will  exercises  used  in  the  present  case,  Bins- 
wanger remarks  that  the  patients  must  be  intelligent  and 
attentive,  and  naturally  they  must  desire  to  get  well.  Fortu- 
nately, many  of  the  war  hysterics  do  want  to  get  well,  since 
the  contrary  experience  is  had  in^^various  industrial  cases. 


SHELL-SHOCK:    NATURE   AND   CAUSES  323 


Wound  of  thigh:  Pseudocoxalgic  monoplegia  with 
anesthesia.  Cure  of  anesthesia  by  faradism  at  one 
sitting.  Cure  of  lameness  by  reeducation  and 
electricity  in  one  month. 


Case  230.     (RoussY  and  Lhermitte,  191 7.) 

An  infantryman,  observed  at  Villejuif,  February  9,  19 15, 
was  suffering  from  a  right-sided  crural  monoplegia  of  a  pseu- 
docoxalgic type,  following  a  wound  September  9,  1914.  The 
wound  had  been  a  through-and-through  one  in  the  upper 
right  thigh.  Every  active  movement  could  be  performed 
as  well  on  the  right  side  as  on  the  left;  but  the  strength  of 
the  movements  was  less  on  the  right,  especially  that  of  leg- 
extension.  The  reflexes  were  normal,  the  lameness  was 
slight,  with  toeing  out;  the  sole  came  down  fiat  upon  the 
ground.  There  was  an  absolutely  complete  anesthesia  of 
the  entire  right  leg  and  side  up  to  the  umbilicus. 

Energetic  faradization  of  the  skin  caused  the  anesthesia 
to  disappear  the  day  the  patient  was  brought  to  the  hospital. 
The  cure  of  the  lameness  required  a  month  of  reeducation 
and  electricity. 

According  to  Roussy  and  Lhermitte,  crural  monoplegia  is 
less  frequent  than  brachial  monoplegia.  The  flaccid  form  Is 
rare,  and  when  It  occurs,  complete,  though  the  patient  al- 
ways remains  capable  of  executing  some  voluntary  move- 
ments and  can  walk  with  crutches  or  cane.  During  the 
automatic  movements  of  walking,  some  muscles  may  be 
observed  to  contract  that  remain  immobile  when  the  patient 
is  being  examined  recumbent.  Naturally  such  a  difference 
In  contractions  standing  and  lying,  would  be  very  exceptional 
in  a  case  of  organic  monoplegia. 


324  SHELL-SHOCK:    NATURE   AND   CAUSES 


Contusion  of  thigh:  HYSTERICAL  right  crural 
MONOPLEGIA.  An  ORGANIC  CRUTCH  PAR- 
ALYSIS develops  in  the  right  arm,  unobserved  by 
the  patient  whose  main  concern  is  his  useless  leg. 
Cure  of  leg  by  psychotherapy. 


Case  231.     (Babinski,  1917.) 

A  certain  lieutenant,  following  contusion  of  the  right 
thigh,  developed  a  crural  monoplegia  of  hysterical  nature. 
In  fact,  although  the  paralysis  had  lasted  several  months,  the 
tendon  reflexes,  the  skin  reflexes,  and  the  electrical  responses 
of  the  muscles,  were  absolutely  normal.  Moreover,  the  good 
effects  of  psychotherapy  confirmed  the  hypothesis.  But 
besides  the  hysterical  crural  monoplegia,  there  was  a  radial 
paralysis  on  the  right  side,  clearly  organic  in  nature,  due  to 
the  nerve  compression  by  the  crutch  which  the  patient  had 
employed  on  account  of  the  paralysis  of  his  leg. 

Babinski  notes  that  this  association  of  conditions  was 
remarkable  in  that  it  demonstrated  that  hysteria  and  simu- 
lation should  not  be  confounded  with  one  another.  To  be 
sure,  it  is  difficult  to  tell  simulation  from  suggested  phe- 
nomena, for  there  are  no  objective  characters  that  demarcate 
the  two.  Babinski  had  himself  said  that  hysteria  was  a 
deml-slmulatlon;  but  a  demi-slmulatlon  is  not  a  simulation. 
The  patient  was  In  fact,  sincere  enough  in  his  belief  that  he 
could  not  move  his  leg.  To  obviate  this  paralysis,  he  had 
in  fact  leaned  so  conscientiously  upon  his  crutch  that  an  or- 
ganic paralysis  had  resulted.  In  fact  the  radial  palsy  had 
only  been  discovered  Incidentally,  and  the  paradox  appeared 
that  a  purely  Imaginary  trouble  occupied  In  the  patient's 
mind  for  a  long  time  a  much  more  Important  place  than  the 
genuine  organic  trouble  which  accompanied  it. 


SHELL-SHOCK:    NATURE   AND   CAUSES  325 


Bombardment;  war  strain;  gassing?;  collapse; 
arthritis:  Hysterical  MONOPLEGIA  and  ANES- 
THESIA of  leg,  interpreted  as  a  **  PROTECTIVE  " 
reaction.     Later,  monoplegia  and  anesthesia  of  arm. 


Case  232.     (MacCurdy,  July,  191 7.) 

A  corporal  described  as  normal  ("  except  for  some  shyness 
with  the  opposite  sex  ")  adapted  himself  well  to  training  and 
went  to  France  in  May,  191 5,  where  he  was  at  once  thrown 
into  18  days  of  almost  continuous  bombardment.  After 
some  Initial  fright,  he  settled  down  to  work  well  enough,  but, 
when  the  weather  got  bad  in  September,  191 5,  grew  tired  of 
the  situation.  Bad  dreams  began  (falling  into  a  deep  hole; 
being  shelled).  He  thought  of  suicide,  wanted  a  shell  to 
incapacitate  or  kill  him,  began  to  have  pains  in  the  head, 
arms  and  legs,  and  was  already  groggy  when  a  gas  attack 
came.  Whether  he  got  a  whiff  of  the  gas  or  not,  he  at  any 
rate  felt  giddy,  got  a  swallow  of  water,  and  when  the  gas 
passed  got  out  of  his  dugout  In  the  open  air.  He  was  fatigued 
and  much  relieved  when  the  company  was  ordered  back. 
Now,  however,  he  got  shaky  and  fell  in  a  collapse  on  a  pile 
of  straw,  without,  however,  losing  consciousness. 

Apparently  he  had  an  attack  of  acute  articular  rheuma- 
tism. There  was  a  sore  throat  and  a  pain  in  the  head, 
radiating  to  left  shoulder  and  to  finger  tips,  with  pain  also 
in  legs.  The  pain  was  worse  in  the  right  leg  on  moving  the 
knee-joint.  These  pains  lasted  for  a  month  in  hospital. 
The  leg  had  been  like  a  log  since  the  collapse  on  the  pile  of 
straw.  Even  after  the  pains  left  him  a  month  later,  the 
right  leg  was  paralyzed  and  anesthetic.  He  walked  with  a 
crutch  and  developed  a  crutch  palsy.  After  a  month  a 
hysterical  paralysis  of  the  right  arm,  with  superficial  anes- 
thesia, supervened.  During  a  period  of  eight  months  there- 
after improvement  was  steady  under  reeducative  measures. 

According  to  MacCurdy's  analysis,  the  acute  arthritis  led  to 
paralysis  as  a  protective  reaction.  The  paralyses  are  disa- 
bilities that  would  ensure  absence  from  the  front. 


326  shell-shock:  nature  and  causes 


Lance-thrust  in  back,  rapidly  healed.  Paralysis  of 
right  leg,  disappearing  with  rest  and  exercises. 
Later,  psychotic  symptoms,  with  recovery. 


Case  233.     (BiNSWANGER,  July,  1915-) 

N.  H.,  21,  a  laborer,  industrious  and  sober  (mother  healthy, 
father  insane  and  a  suicide;  patient  somewhat  sickly  in 
childhood  after  pneumonia,  a  good  scholar)  volunteered  at 
the  outbreak  of  the  war.  Early  in  November  he  was  on  the 
Eastern  front.  November  17  to  22  he  was  in  a  number  of 
small  reconnoitring  skirmishes  almost  dally,  as  a  cavalry- 
man. On  the  22d,  there  was  a  clash  with  a  Cossack  patrol 
of  far  superior  numbers.  Eight  German  horsemen  cut  their 
way  through,  riding  about  4  kilometers  back  to  their  squad- 
ron. 

While  dismounting,  N.  H.  discovered  that  his  back  was 
wet.  It  occurred  to  him  at  once  that  he  had  been  wounded. 
However,  he  successfully  dismounted  and  then  collapsed, 
feeling  as  if  his  right  leg  had  fallen  asleep.  His  companions 
found  a  wound  in  his  back,  which  had  come  from  a  lance- 
thrust.  The  wound  was  bandaged.  He  was  transported  to 
Germany  on  a  peasant's  wagon,  the  trip  occupying  six  days, 
and  on  December  6  he  came  to  the  surgical  clinic  in  Jena. 
The  wound  was  insignificant  and  healed  quickly. 

The  leg  remained  motionless,  and  on  December  10  the 
patient  was  referred  to  the  nerve  hospital.  He  was  a  small, 
slenderly-built  man,  with  poor  nutrition,  weighing  108 
pounds.  The  scar,  about  i  cm.  long,  alongside  the  thoracic 
vertebra,  was  still  somewhat  red  and  but  slightly  sensitive 
to  pressure.  Neurologlcally,  the  knee-jerks  and  Achilles 
jerks  were  greater  on  the  right  than  on  the  left,  and  there 
was  on  the  right  side  a  distinct  patella  and  ankle  clonus. 
There  was  no  BablnskI  reaction  on  either  side. 

The  movements  of  the  right  leg  were  not  of  wide  excursion, 
and  flexion  and  extension  of  the  knee  and  ankle-joints,  while 
lying  on  the  back,  were  slowly  and  hesitatingly  performed, 
with  an  expression  of  pain,  and  with  visible  effort  by  the 


SHELL-SHOCK:    NATURE   AND   CAUSES  327 

quadriceps  muscles.  Flexion  and  extension  of  the  toes  were 
likewise  difficult,  and  when  the  toes  were  stretched  there  was 
a  distinct  contraction  of  the  tibialis  anticus.  Electrically 
the  muscles  were  normal.  On  passive  motion,  there  was 
slight  spastic  tension  in  the  musculature  of  the  right  leg,  and 
the  patient  said  he  felt  marked  pain.  In  walking,  the  right 
leg  was  moved  with  a  limp  and  with  the  evident  design  of 
sparing  it.  The  knee  was  imperfectly  bent  and  the  sole  of 
the  foot  was  dragged  along  the  ground.  There  were  short 
out-throwing  movements  of  the  lower  leg. 

Pain  sense  was  normal,  or  possibly  slightly  in  excess. 
There  were  painful  points  on  pressure  on  the  lower  part  of 
the  OS  sacrum  and  coccyx  and  over  the  right  sciatic  and  tibial 
nerves.  Intelligence  examination  showed  school  knowledge 
to  be  extremely  poor  and  calculation  ability  poor.  Critical 
judgment  and  reasoning  power  were  deficient.  Memory 
and  perception  were  without  marked  disturbance.  The 
patient  was  dull  and  without  Interest  in  his  surroundings. 
He  complained  that  his  right  leg  was  as  if  dead  and  that  he 
felt  great  pain  in  any  attempt  to  move  it.  He  also  complained 
of  pains  at  night  in  the  region  of  the  right  shoulder  and  neck. 
His  nerves,  he  said,  had  been  very  weak  since  his  trip  back 
from  the  front,  during  which  trip  he  had  been  very  cold  and 
poorly  cared  for. 

Treatment  consisted  of  rest  In  bed,  application  of  moist 
packs  to  the  right  leg,  active  and  passive  exercises  of  the 
right  leg.  After  ten  days  he  made  his  first  Independent 
attempts  to  walk,  and  active  movements  of  the  right  leg  In 
dorsal  decubitus  became  unrestricted  and  painless.  He  re- 
mained somewhat  unsteady  In  station,  showing  bilateral 
twitchings  and  movements  of  the  right  leg  muscles.  In 
walking  the  right  leg  was  dragged  behind  in  a  spastic-paretic 
fashion.  Appetite  improved ;  spasms  decreased ;  but  at  the 
end  of  December  foot  clonus  was  still  persistent. 

Upon  January  10  there  was  an  odd  mental  change.  He 
became  seclusive  and  suspicious.  January  15  he  expressed 
ideas  of  poisoning;  his  sister,  he  said,  wanted  to  poison 
him,  and  others  were  watching  him  suspiciously;  his  room- 
mates  were   talking   about   him;    in   fact,  he  thought  one 


328  SHELL-SHOCK:    NATURE   AND   CAUSES 

comrade  was  an  Englishman.  Sleep  was  poor.  At  the  end 
of  January,  after  a  short  period  of  improvement,  he  again 
had  ideas  of  being  poisoned,  and  had  dream-like,  unclear 
thoughts.  His  actions  became  incoherent:  he  would  un- 
dress suddenly  in  the  daytime  and  go  to  bed,  getting  up  five 
minutes  later  and  dressing.     Senseless  postcards  were  written. 

This  condition  lasted  a  few  days  only,  whereupon  the 
mental  and  bodily  condition  greatly  improved.  Daily  walks 
were  then  taken  in  the  garden  and  in  the  city  without  ex- 
ertion. The  ankle-clonus  on  the  right  side  was  now  decidedly 
weaker  but  did  not  entirely  disappear.  The  muscle  power  on 
the  right  side  was  somewhat  less  than  on  the  left. 

The  patient  was  very  homesick,  and  on  March  14  was 
sent  home. 


shell-shock:   nature  and  causes  329 


Shell-shock  —  six  days  later,  crural  monoplegia, 
cured  by  suggestion.  "Metatraumatic"  hysteria. 
HYPERSENSITIVE  PHASE  AFTER  SHELL- 
SHOCK. 


Case  234.     (Schuster,  January,  191 6.) 

On  August  13,  1 91 5,  a  soldier  was  knocked  unconscious 
by  the  explosion  of  a  shell  nearby.  He  woke  up  several 
hours  later  with  headache,  noises  in  the  ears,  itching,  but  no 
trace  of  paralysis. 

Six  days  later,  on  August  19,  he  was  released  from  hospital, 
still  free  from  paralysis.  On  the  railway  journey  he  met 
some  people  of  his  district  by  whom  he  sent  greetings  to  his 
wife,  meanwhile  becoming  greatly  excited.  When  he  tried 
to  get  out  of  the  train  he  noted  a  weakness  of  the  left  arm  and 
left  leg;  this  weakness  somewhat  quickly  grew  into  a  severe 
paralysis,  so  that  when  observed  in  Berlin  the  left  leg  was 
entirely  paralyzed,  not  a  single  muscle  of  which  could  be 
moved  when  the  patient  was  examined  by  Schuster  one 
month  after  the  accident.  There  was  also  a  hypesthesia  on 
the  left  side  with  total  anesthesia  of  the  left  leg,  which 
anesthesia  was  related  stocking-wise  to  the  hypesthesia  of 
the  trunk.  There  was  tremor  of  the  hands  as  well  as  general- 
ized increase  of  reflexes.  The  plantar  reflex,  though  weak, 
was  flexor.  The  pulse  rapidly  ran  up  under  excitement.  In 
short,  the  patient  seemed  to  be  suffering  from  hysterical 
palsy.  Waking  suggestion  did  so  well  with  the  man  that 
after  three  weeks  normal  sensibility  was  restored  to  the  leg, 
and  he  could  walk  tolerably  well  withou,t  a  cane. 

The  point  of  interest  in  this  case  is  that  the  symptom  of 
greatest  importance,  namely  paralysis  of  the  left  leg,  did  not 
arise  until  six  days  after  the  shell  explosion  and  then  only 
after  the  man  became  excited  by  thoughts  of  his  home  and 
family  through  meeting  his  town  people.  The  term  meta- 
traumatic  is  suggested  by  Schuster  for  cases  of  this  sort.  The 
emotions  and  stresses  of  war  may  be  regarded  as  labilizing 
and  sensibilizing  the  nervous  system  sometimes  for  months. 


330  SHELL-SHOCK:    NATURE   AND   CAUSES 


Wound  of  left  foot:  ACRO  CONTRACTURE. 
Psychoelectric  cure,  about  seven  months  later,  at 
one  sitting,  except  for  some  residuals  that  cleared 
shortly  afterwards. 


Case  235.     (RoussY  and  Lhermitte,  191 7.) 

A  soldier,  21  years,  was  observed  at  the  Centre  Neuro- 
psychiatrique,  August  30,  191 6.  He  had  been  wounded  in 
battle,  March  16,  191 6,  near  the  left  internal  malleolus. 
Infection  followed  and  inguinal  adenitis,  for  which  he  was  in 
hospital  a  month. 

Even  before  the  abscess  began,  the  foot  had  begun  to  twist 
inward.  After  the  abscess  had  been  cured,  a  contracture 
set  in  permanently,  and  at  entrance  to  hospital  was  irredu- 
cible. The  knee-jerk  and  Achilles  jerk  were  more  active  on 
the  side  of  the  equinovarus  contracture.  There  was  even  a 
slight  amyotrophy  of  the  calf.  There  was  no  appreciable 
vasomotor  disorder.  The  foot  and  lower  part  of  the  leg  were 
a  little  warmer  on  the  left  side. 

Cure  followed  a  single  sitting  with  psychoelectric  treat- 
ment, at  least  so  far  as  the  contracture  went.  Pain  and 
swelling  remained  in  the  evening,  followed  by  fatigue.  The 
patient  was  discharged  cured,  October  12,  1916. 

Hysterical  pes  equinovarus  shows  the  foot  immobile  as  if 
frozen  (fige).  The  foot  is  extended  with  the  toes  lowered 
and  the  internal  border  incurved,  as  if  revolved  about  the 
axis  of  the  leg.  The  surface  of  the  sole  is  directed  inwards 
and  much  furrowed.  The  tendon  of  the  tibialis  anticus  is 
very  prominent.  The  internal  malleolus  is  hardly  visible, 
while  the  head  of  the  astragalus  is  easily  made  out.  No 
passive  movement  is  possible  and  the  tibiotarsal  and  medlo- 
tarsal  joints  are  quite  out  of  function.  Upon  palpation,  the 
excessive  contracture  of  the  anterior  muscles  of  the  leg  is 
striking.  Upon  request  to  move  the  foot,  the  foot  is  not 
moved,  but  muscles  of  the  lower  leg  may  contract,  and  even 
those  of  the  thigh. 


shell-shock:  nature  and  causes  331 

There  were  no  sensory  disorders  in  the  present  case,  though 
they  often  do  occur  in  this  form  of  acrocontracture.  It  is 
doubtful  whether  the  skin  changes  sometimes  seen,  such  as 
hypothermia,  hyperidrosis,  cyanosis,  and  glossiness  are  due 
to  circulatory  disorder  induced  by  the  contracture  or  to  the 
prolonged  immobility.  It  has  been  proved  by  Meige,  Benisty 
and  Levy,  that  even  in  a  normal  subject  prolonged  immo- 
bility may  cause  a  difference  of  temperature  of  several  degrees. 
Circulatory  disorders  sometimes  cease  immediately  upon 
cessation  of  the  contracture.  Roussy  and  Lhermitte  insist 
upon  energetic  and  early  treatment  of  these  psychoneuro- 
pathic  acrocontractures,  which  are  apt  to  proceed  less 
favorably  than  the  acroparalyses.  If  not  treated  energeti- 
cally and  early,  actual  nerve,  tendon,  and  bone  lesions  may 
ensue. 


332  SHELL-SHOCK:     NATURE   AND  CAUSES 


Shell-shock;     shell-wound;     emotion;    Hysterical 
paraplegia.     Approximate  recovery. 


Case  236.     (Abrahams,  July,  191 5.) 

A  private  of  the  First  East  Lanes  could  remember  a 
shell's  bursting  and  striking  a  wagon  near  him  when  he  was 
carrying  food  to  the  firing-line.  He  also  thought  a  spare 
wagon  wheel  might  have  fallen  on  him.  A  period  of  uncon- 
sciousness of  four  or  five  days  duration  elapsed,  on  recovery 
from  which  he  found  himself  suffering  from  a  shell -wound  in 
the  left  buttock,  complete  paralysis  of  both  legs,  and  pain  in 
the  back,  by  the  fourth  lumbar  vertebra.  He  thought  that 
he  had  suffered  from  sphincteric  paralysis  for  eleven  days  af- 
ter the  accident;  but  by  September  25,  there  was  no  sign  of 
this.  Besides  the  paraplegia,  there  was  complete  loss  of  sen- 
sation below  Poupart's  ligament  in  the  right  leg,  reaching  as 
high  as  the  iliac  crest  behind;  and  an  anesthesia  of  the  left 
foot  including  heel  and  sole,  with  anesthesia  to  light  touch 
throughout  the  limb  (pin-pricks  being  appreciated  in  a  nor- 
mal way  as  far  as  the  ankle) ;  and  there  was  an  anesthesia  to 
touch  and  pain  in  the  ulnar  distribution. 

April  20,  1915,  the  patient  was  found  to  be  a  robust, 
somewhat  micrencephalic,  slowly  cerebrating  subject.  Total 
flaccid  paralysis  of  legs;  right  knee-jerk  slightly  exaggerated; 
no  plantar  response  of  any  sort  was  obtainable.  Right  leg 
entirely  anesthetic ;  left  leg  and  both  arms  showed  a  dimin- 
ution of  sensibility;  suggestion  of  glove  and  stocking  anes- 
thesia; trophic  changes  absent.  The  scar  of  the  healed 
bullet-wound  lay  over  the  trunk  of  the  left  sciatic  nerve. 

It  seems  that  the  man's  companion  had  both  his  legs 
blown  off  at  the  time  the  shell  burst.  It  is  questionable 
whether  the  paraplegic  patient  actually  saw  the  legs  blown 
off,  or  merely  heard  about  the  accident.  Another  psychic 
feature  lay  in  the  fact  that  the  patient  had  a  paralyzed 
sister  —  a  possible  financial  burden. 

April  30,  nitrous  acid  anesthesia.  During  the  temporary 
rigidity,  the  legs  were  found  to  stiffen  slightly;  the  legs  were 


SHELL-SHOCK:  NATURE  AND  CAUSES         333 

flexed,  upon  the  return  of  consciousness,  the  patient  was 
told  that  the  legs  had  moved  during  anesthesia,  and  was 
asked  to  place  them  in  a  more  convenient  position.  The 
thighs  moved  slightly,  and  throughout  the  day  movements 
were  encouraged  against  resistance. 

The  next  day  he  was  gradually  raised  to  the  vertical 
position  and  supported  upright.  But  at  this  stage  he  had 
become  mentally  resistant  and  resentful.  During  the  day 
the  upright  position  was  at  intervals  resumed,  and  the  patient 
was  made  to  walk  between  two  attendants.  The  next  day 
he  walked  alone  and  his  mental  resistance  had  broken  down. 
There  was  no  longer  any  evidence  of  exhaustion  and  effort 
in  the  movements,  and  the  patient  began  to  take  pleasure  in 
his  recovery. 

Improvement  was  progressive.  A  pronounced  hysterical 
element  persisted,  encouraged  by  the  perpetual  attentions  of 
visitors.  When  discharged,  there  was  a  slight  hemi-anes- 
thesla  throughout  the  right  side,  and  a  doubtful  patch  of 
anesthesia  on  the  dorsum  of  the  foot,  sole,  and  plantar  sur- 
face of  the  heel. 


334  SHELL-SHOCK:     NATURE   AND   CAUSES 


Shell-shock;  burial;  flexion  of  spine:  Paraplegia. 


Case  237.     (Elliot,  December,  1914.) 

A  reservist,  34,  formerly  army  Instructor  in  gymnastics,  a 
member  of  the  1st  Battalion  King's  Royal  Rifles,  was  sub- 
ject to  Injury  from  the  bursting  of  a  "Black  Maria  "  on  his 
trench.  He  was  sitting  with  bent  back  in  his  shelter,  with 
legs  fully  extended.  He  was  In  a  small  dug-out,  a  recess 
excavated  under  the  earth  backward  from  a  narrow  trench 
and  not  timbered.  The  "Black  Maria"  burst  and  covered 
him  up  to  the  chin  in  a  heavy  clay  soil.  After  building  up 
the  breach  twenty  minutes  later,  his  comrades  dug  him  out. 

He  had  received  on  his  body  the  violent  Impact  of  the  mass 
of  earth  pushed  laterally  from  the  crater  excavated  by  the 
bursting  of  the  shell.  Accordingly  his  vertebral  column  was 
forcibly  flexed.  Its  ligaments  were  stretched,  and  hemorrhages 
were  produced  in  the  great  muscles  of  the  back.  As  the 
twelfth  thoracic  vertebra  is  the  weakest  spot  In  the  spine, 
the  roots  of  the  cauda  equina  opposite  this  weak  spot  were 
probably  Injured.     Such  accidents  are  met  in  mines. 

The  legs  were  powerless  and  numb.  There  was  nausea, 
no  vomiting,  no  gas,  no  dizziness  or  trouble  in  the  head, 
not  even  pain  in  the  small  of  the  back.  The  accident  had 
occurred  at  8  a.m.  Upon  nightfall,  he  was  removed  on  a 
stretcher  to  the  field  hospital,  arriving  at  the  base  hospital 
four  days  later;  and  on  the  fifth  day  power  began  to  return 
to  the  legs.  Knees,  ankles,  and  toes  would  move  slightly 
November  6,  though  passive  movements  of  the  legs  caused 
pain  in  the  back.  The  deep  reflexes  were  weak,  the  plantar 
reflexes  flexor.  The  left  cremasteric  reflex  was  weaker  than 
the  right.  Impairment  of  sensation  was  slight  in  both  ex- 
tremities, but  the  left  leg  was  a  little  more  numb  than  the 
right.  The  left  lower  abdominal  reflex  was  lost.  A  band  of 
hyperalgesia  corresponded  with  the  left  eleventh  and  twelfth 
thoracic  segments  November  12,  slight  reflex  disorders  and 
some  degree  of  paresis  of  the  legs. 


SHELL-SHOCK:    NATURE   AND   CAUSES  335 


Shell  explosion:    Paraplegia;    sensory  symptoms. 


Case  238.     (Hurst,  January,  191 5.) 

A  lieutenant,  23,  came  to  the  ambulance  September  15, 
1914,  having  the  morning  before  been  to  the  firing-line  with 
his  company  and  thrown  to  the  ground  on  his  back  by  the 
explosion  of  a  shell  which  he  had  seen  falling  behind  him. 
He  had  not  lost  consciousness,  but  was  unable  to  rise.  After 
a  night  in  the  relief  post,  he  was  brought  by  automobile  12 
kilometers  to  the  ambulance.  He  complained  of  pain  in  the 
back,  though  no  wound  or  ecchymosis  could  be  found  there, 
nor  any  painfulness  of  spinous  processes  or  irregularity  of 
bone.  He  had  not  emptied  the  bladder  from  the  time  of 
the  shock.  Preparations  were  made  to  catheterize  on  the 
morning  of  the  1 6th,  when  the  patient  after  effort  became 
able  to  micturate.  There  was  crural  paraplegia  such  that 
he  could  not  sit  or  walk  even  when  supported.  Lying  down, 
he  could  move  his  legs  slightly  sidewise.  Anesthesia  to  pin- 
prick and  temperature  was  complete  to  the  groin ;  but  tactile 
anesthesia  was  found  only  in  the  sacral  root  territory,  namely 
in  the  feet,  the  outer  aspect  of  the  legs,  the  posterior  surface 
of  the  thighs,  and  the  scrotum.  There  was  loss  of  sense  of 
position  for  the  toes.  The  plantar  reflexes  were  abolished; 
but  there  were  no  other  reflex  disorders;  nor  was  there  any 
evidence  of  other  disorder. 

September  20,  the  man  was  evacuated  by  sanitary  train 
in  the  same  status  as  at  entry.  January  2'],  191 5,  the  patient 
could  walk  on  crutches,  supporting  himself  in  part  on  the 
left  leg.     The  lumbar  pain  had  largely  disappeared. 

Hurst  regarded  this  case  as  one  of  organic  origin  due  to 
commotio  spinalis. 


336  shell-shock:   nature  and  causes 


Wet,  cold,  heavy  marching;  leg  pains,  rheumatic; 
no  other  somatic  factor  or  any  emotional  factor  dis- 
coverable :  Transient  paraplegia ;  two  months  after 
period  of  exposure,  brachial  tremor,  hysterical. 
Recovery  incomplete. 


Case  239.     (Binswanger,  July,  191 5.) 

A  German  soldier,  34  (non-alcoholic;  married,  father  of 
five  healthy  children;  on  military  service  1901-3;  regarded 
as  a  very  good  soldier;  father  alcoholic),  got  bad  leg  pains 
from  wet  and  cold  in  West  front  trenches  September  8-13, 
1 914.  Still  he  was  able  to  march  some  30  kilometers.  But 
two  days  later  (he  had  lain  down  in  wet  clothes  in  a  barn), 
his  legs  became  quite  immobile.  He  was  in  a  reserve  hos- 
pital from  November  3.  The  rheumatism  disappeared,  and 
suddenly,  early  in  the  morning  of  November  8,  when  he  was 
washing,  a  lively  tremor  and  shaking  of  the  right  arm  set  in. 

Examination  at  Jena  January  30,  191 5,  showed  no  special 
physical  disorder.  The  sense  of  touch  was  slightly  dimin- 
ished on  the  right  side;  the  pain  sense  was  normal;  move- 
ments were  free.  While  at  rest  there  was  a  continuous 
shaking  tremor  of  the  right  arm  and  hand,  which  consisted 
of  very  rapid  pronations  and  supinations,  and  shaking  move- 
ments of  the  upper  arm.  At  times  the  tremor  would  com- 
pletely cease,  and  when  attention  was  diverted  the  tremor 
became  slighter  or  quite  disappeared.  The  tremor  increased 
when  it  was  talked  about  in  the  man's  presence.  The  left 
grip  was  stronger  than  the  right. 

January  31,  after  he  had  been  in  bed  one  day  and  treated 
with  moist  packs,  the  shaking  suddenly  ceased.  He  then 
complained  only  of  mild  pains  in  the  right  shoulder  and 
wanted  to  get  up. 

February  23,  he  was  given  three  days*  home  leave,  which 
he  stood  very  well.  He  now  began  to  take  part  in  the 
medical  gymnastic  work,  but  complained  afterwards  of  more 
pains  in  right  shoulder  and  arm.     There  was  a  lapse  into  the 


SHELL-SHOCK:    NATURE   AND  CAUSES  337 

shaking  tremor,  which  lasted  with  varying  intensity  for 
several  weeks.     Loud  noises  or  calling  made  it  worse. 

Hypnotism  and  suggestive  treatment  of  the  tremor  were 
without  effect  March  25.  March  26,  on  passive  extension 
of  the  right  arm,  patient  complained  of  pain  in  shoulder  and 
arm.  Next  day  the  tremors  were  more  marked,  but  March 
29,  the  tremors  suddenly  stopped  altogether.  April  4,  the 
pains  stopped  never  to  return.  April  15,  he  was  given  leave 
to  go  home  for  spring  farm  work. 

Four  weeks  later  he  returned,  sparing  his  right  arm,  which 
he  held  stiffly  beside  his  body  when  walking.  If  he  let  the 
arm  hang  free  In  walking,  rhythmical  movements  in  it  began. 
He  complained  of  painful  Involuntary  contractions  In  the 
right  arm  even  when  in  complete  rest.  Nor  did  the  con- 
dition afterward  essentially  change;  the  patient  went  home 
at  the  beginning  of  July. 

The  remarkable  feature  of  this  case  is  the  complete  lack  of 
any  emotional  shock.  The  total  genesis  seems  to  have  con- 
sisted In  the  prolonged  exposure  to  wet  and  cold,  and  the 
heavy  marching.  The  tremors,  limited  to  the  right  upper 
extremity,  occurred  without  any  demonstrable  psychic  or 
bodily  trouble,  and  set  in  after  the  disappearance  of  the  so- 
called  rheumatic  disorder.  Although  there  is  no  one  psycho- 
genic factor  to  single  out,  the  psychic  infiuencibility  of  the  case 
is  unmistakable;  moreover,  the  incompleteness  of  the  cure  is 
doubtless,  according  to  Binswanger,  a  matter  of  the  imper- 
fect suggestive  therapy  employed. 


338  shell-shock:   nature  and  causes 


Fever   patient   watches   barrage    coming:    uncon- 
sciousness, paraplegia:  recovery. 


Case  240.     (Mann,  June,  191 5.) 

A  lieutenant  was  lying  with  fever  in  a  farmhouse  in  upper 
Alsace,  watching  from  his  window  the  shelling  of  a  battery 
about  400  meters  away.  He  saw  that  the  enemy  was  to 
reach  the  farm  with  shell  in  due  course  of  time.  The  shells 
came  nearer,  say  up  to  about  100  meters,  and  the  lieutenant 
was  able  to  reckon  closely  when  he  would  be  reached.  He 
was  quite  defenseless  and  unable  to  get  to  safety.  At  the 
very  moment,  he  thinks,  when  the  shells  began  to  strike  the 
house,  the  lieutenant  lost  consciousness  from  fear.  He  was 
unconscious  an  hour  before  being  carried  to  the  cellar.  The 
shelling  lasted  several  hours  more.  Immediately  upon  com- 
ing to  the  patient  found  that,  although  he  bore  no  external 
wound,  both  legs  and  the  right  arm  were  paralyzed. 

There  were  never  any  signs  of  organic  disorder.  The  pa- 
tient recovered  completely  with  purely  suggestive  treatment. 


Incentives  to  paraplegia. 


Case  241.     (RussEL,  August,  191 7.) 

A  young  Canadian  paid  $150  to  have  his  teeth  repaired 
to  be  accepted  for  service  and  then  married.  The  wife 
became  pregnant.  He  reported  sick  after  falling  out  on  a 
route  march  in  a  heavy  rainstorm.  The  medical  ofhcer  said 
he  had  weak  feet  and  ankles.  He  lay  around  the  huts,  was 
excused  duty,  and  got  worse  in  the  wet  and  cold.  He  was 
admitted  to  hospital  and  came  to  Russel's  wards  on  a 
stretcher  showing  paralysis  of  both  legs  with  slight  power  of 
movement  at  the  knee.  Stroking  anesthesia  to  pin  prick 
from  the  knee  down.  Reflexes  not  abnormal.  He  walked 
back  upstairs! 

According  to  Russel  the  wife's  pregnancy  had  furnished  a 
sufhcient  incentive,  and  the  M.  O.'s  suggestion  had  fallen  on 
fertile  soil. 


SHELL-SHOCK:    NATURE  AND   CAUSES  339 


Bullet  wound  of  back:    Hysterical  bent-back 
camptocormia. 


Case  242.     (SouQUES,  February,  191 5.) 

A  man  was  wounded  September  6,  1914,  by  a  bullet  that 
entered  along  the  axillary  border  of  the  scapula  and  emerged 
near  the  spine.  He  spat  blood  for  several  days ;  but  the  skin 
wounds  quickly  healed. 

When  he  got  up,  his  trunk  and  thighs  were  found  to  be  in  a 
state  of  moderate  flexion  upon  the  pelvis,  the  trunk  being  bent 
almost  at  a  right  angle ;  the  legs  were  flexed  somewhat  upon 
the  thighs.  The  man  could  not  voluntarily  extend  his  trunk, 
but  he  could  extend  his  thighs  to  a  moderate  degree.  He 
could  bend  his  trunk  still  further  forward  than  its  habitual 
contractured  position,  being  able  to  pick  up  an  object  from 
the  ground.  If  the  man  was  put  in  the  ventral  position,  the 
trunk  could  be  straightened  to  a  considerable  degree.  Curi- 
ously enough,  the  man  felt  no  pain,  nor  had  there  been  any 
pain  since  the  healing  of  the  wound.  No  motor,  sensory, 
reflex,  trophic,  vasomotor,  electrical,  visceral,  or  X-ray  dis- 
orders could  be  found.  It  was  evident  that  there  was  a 
contraction  of  the  muscles  of  the  abdominal  wall  and  of  the 
iliopsoas,  yet  it  was  also  clear  that  these  muscles  were  not 
contractured  on  account  of  the  subject's  ability  to  flex  his 
trunk  and  to  extend  his  thighs. 

Here,  then,  is  a  vicious  attitude  crystallized  (in  the  phrase 
of  Souques)  in  the  form  of  a  pseudocontracture. 


340  shell-shock:  nature  and  causes 


Blown   up   by    shell ;    unconsciousness :     Campto  - 
connia  (bent-back,  **  cintrage  ").     Cure  by  corsets. 


Case  243.     (RoussY  and  Lhermitte,  1917.) 

Camptocormia  with  antero  lateral  bending  is  described 
by  Roussy  and  Lhermitte  in  an  infantryman  observed  at 
Villejuif,  February,  191 5,  after  having  been  wounded  Septem- 
ber 3,  1 9 14.  The  infantryman  had  been  thrown  into  the 
air  by  the  bursting  of  a  shell,  had  lost  consciousness,  and 
came  to  with  violent  pains  in  the  back.  The  trunk  was 
found  to  be  bent  strongly  forward  and  to  the  right  side,  and 
remained  in  this  position  thereafter.  There  was  no  evidence 
of  wound. 

In  February,  1916,  a  plaster  corset  was  applied  by  Souques, 
which  brought  the  patient  partly  to  normal  station  in  three 
weeks.  The  trunk  was  now  no  longer  bent  forward,  but  was 
still  bent  to  the  right.  A  second  corset  was  applied  for 
three  more  weeks,  with  which  the  patient  became  absolutely 
straightened  out  again.  He  was  discharged  cured  and  sent 
to  the  Grand- Palais  for  the  reeducation  course. 

This  condition  is  a  form  of  trunk  contracture  in  the  nature 
of  a  kyphosis  (scoliotic  and  lordotic  forms  of  contracture  are 
also  found  in  the  hysterical  group) ,  for  which  the  terms  plica- 
ture  of  trunk,  traumatic  kyphosis,  pseudo-spondylitis,  and 
camptocormia  have  been  in  use.  The  term  camptocormia 
has  been  proposed  by  Souques  and  Rosanoff-Saloflf.  The 
poilus  speak  of  the  condition  as  cintrage  (arching).  In  these 
cases  the  trunk  is  held  almost  horizontally,  with  the  head  in 
hypertension  and  neck  muscles  and  thyroid  cartilage  jutting. 
The  patient  looks  fixedly  straight  forward,  with  eyes  wide 
open,  and  carries  his  legs  extended  or  half  flexed.  The  nor- 
mal folds  of  the  abdominal  wall  are  very  deeply  marked,  and 
at  the  level  of  the  groins,  the  epigastrium  and  the  pubis, 
there  are  deep  folds.  Viewed  from  behind,  the  median 
lumbar  fold  has  disappeared  or  is  faintly  marked,  as  are  the 
sacro-lumbar  and  other  masses  of  spinal  muscles.  The 
whole  lumbar  region  is  elongated  and  flattened.     The  dorsal 


shell-shock:   nature  and  causes  341 

spines  of  the  back  are  accentuated ;  the  buttocks  are  flattened 
and  broadened  transversely.  The  back  of  the  neck  is 
marked  by  deep  transverse  folds,  and  the  seventh  spine  does 
not  stand  out.  The  patient  can  walk  perfectly,  though 
sometimes  there  is  a  pseudocoxalgia  and  lameness.  At- 
tempts to  straighten  the  body  lead  to  visible  forcible  contrac- 
tions of  various  muscles,  but  the  kyphosis  remains  persistent. 
There  is  a  sense  of  active  resistance  on  the  part  of  the  patient, 
which  can  be  demonstrated  by  palpation.  If  an  active 
attempt  at  straightening  is  made,  lumbar  or  sacral  pain 
develops,  followed  by  a  very  lively  and  emotional  state  of 
anxiety  on  the  part  of  the  patient,  with  interrupted  and 
accelerated  breathing,  an  expression  of  terror  in  the  face,  and 
a  rapid  pulse.  The  patient  then  subsides  into  his  earlier 
attitude,  and  his  anxiety  disappears  in  a  few  seconds.  It  is 
much  easier  in  many  subjects  to  reduce  the  camptocormia  in 
the  position  of  dorsal  decubitus  than  upright. 


34^  SHELL-SHOCK:    NATURE  AND  CAUSES 


Burial  after  shell  explosion;  lumbar  eccli3mioses ; 
regionary  pains ;  camptocormia,  5V2  months.  Cure 
by  three  months'  plaster  cast  about  trunk. 


Case  244.     (RoussY  and  Lhermitte,  1917.) 

An  infantryman  was  buried  after  shell  explosion  August 
25,  1914,  but  he  sustained  no  wound  or  bone  injury.  There 
was,  however,  a  large  ecchymosis  of  the  lumbar  region,  and  he 
had  felt  violent  lumbar  pains.  The  trunk  was  carried  flexed, 
symmetrically  bent  over  and  quite  incapable  of  being 
straightened  completely.  A  plaster  corset  was  applied  March 
16  by  Souques.  Three  months  of  this  was  followed  by  a 
complete  straightening,  which  lasted  after  the  corset  was 
removed.     The  patient  was  discharged  well. 

As  to  these  cases  of  camptocormia,  some  authors  regard 
them  as  due  to  anatomical  changes  in  the  vertebral  column 
itself,  or  in  the  ligaments  and  muscles,  and  accordingly  regard 
the  condition  as  a  form  of  spondylitis,  syndesmitis,  or  psoitis. 
This  view  is  held  by  Sicard,  who  bases  the  idea  upon  the 
local  pains  and  the  results  of  cerebrospinal  fluid  examination. 
According  to  Roussy  and  Lhermitte,  hyperalbuminosis  of  the 
fluid  is  extremely  rare,  and  one  case  of  their  own  with  hyperal- 
buminosis was  nevertheless  cured  with  great  rapidity. 
Roussy  and  Lhermitte  even  inquire  whether  the  fluid  albumin 
may  not  be  due  in  some  way  to  an  interference  with  venous 
and  lymphatic  circulation. 

In  some  cases,  this  condition  may  be  at  first  a  response  to 
pain,  a  pseudospondylitis  dolorosa,  such  as  may  be  some- 
times observed  in  hospitals  near  the  front.  Later,  however, 
the  suffering  in  camptocormia  is  due  more  to  the  abnormal 
position  of  the  trunk,  with  strain  upon  vertebral  ligaments, 
than  to  the  persistence  of  any  original  pain.  Moreover, 
these  patients  recover  almost  immediately  from  their  pains 
when  the  contraction  is  relieved. 

In  differential  diagnosis,  one  has  to  consider,  according  to 
Roussy  and  Lhermitte,  Pott's  disease,  traumatic  spondy- 
litis, as  well  as  Bechterew's  vertebral  ankylosis,  Pierre  Marie's 


SHELL-SHOCK:    NATURE  AND  CAUSES  343 

rhizomellc  spondylosis,  Kocher's  intervertebral  disc  contu- 
sions, and  Schuster's  myogenic  ankylosis  of  the  vertebral 
column;  but  in  Pott's  disease,  the  fixed  pain  points,  rigidity 
of  column,  fluid  examination,  and  signs  of  myelitis,  should 
suffice  for  the  differential  diagnosis.  Traumatic  spondylitis 
follows  the  contusion  after  months  and  after  a  phase  of  neu- 
ralgia. Ankyloses  do  not  so  much  concern  the  trunk  as  the 
vertebral  column  itself;  disc  contusion  produces  disorders  in 
standing  and  gait  as  well  as  pains  and  edema.  Schuster's 
disease  shows  paresis,  hyper  refiexia,  and  amyotrophy  not 
shown  in  camptocormia. 


344  SHELL-SHOCK:    NATURE  AND  CAUSES 


Shell  explosion;  partial  burial;  forcible  flexion  of 
spine.  Paraplegia,  cured  by  suggestion.  Then 
camptocormia,  also  cured. 


Case  245.     (JoLTRAiN,  March,  191 7.) 

An  infantryman  in  the  Cote  du  Poivre  was  sitting  on  the 
ground  in  the  opening  of  a  dugout  eating  soup,  when  a  shell 
burst  and  the  roof  of  the  sap  fell  in  on  him.  The  planks  and 
the  stonework  fell  heavily  on  the  dorsolumbar  region.  The 
patient  was  almost  bent  in  two,  head  to  knees,  legs  buried, 
hardly  able  to  breathe.  He  did  not  lose  consciousness  and 
cried  out,  feeling  for  a  moment  very  anxious  and  fearful  that 
his  comrades  had  left.  Only  two  hours  later  was  it  possible 
to  dig  him  out.  He  said  he  had  been  absolutely  unable  to 
make  any  movement,  had  kept  his  body  bent,  and  felt  violent 
pains  in  the  back.  He  was  carried  back  twelve  hours  later 
and  reached  the  dressing  station  in  eight  more  hours,  eventu- 
ally reaching  the  neurological  service  two  days  and  a  half 
after  the  accident.  On  entrance  he  was  prostrated,  com- 
plained of  lumbar  pains  and  of  inability  to  move,  and  was 
able  to  make  only  a  few  contractions  on  the  left  side  when 
asked  to  try.  The  right  leg  was  flaccid.  The  left  knee-jerk 
was  stronger  than  the  right.  Other  reflexes  normal.  Hy- 
peresthesia to  pin  prick  on  the  right  side.  Slight  saddle 
hypesthesia,  reaching  to  the  iliac  crests  above  and  perineum 
below  with  preservation  of  touch  sensation.  Slight  forward 
posture  of  vertebral  column.  The  patient  complained  of 
pain  on  pressure  of  the  spinal  processes  and  the  lumbar  spine. 
There  was  slight  ecchymosis  about  the  left  iliac  crest. 

Lumbar  puncture  showed  clear  fluid  without  hypertension, 
in  which  were  a  few  lymphocytes.  There  was  a  large  amount 
of  albumin.  The  blood  pressure  was  normal.  There  had  been 
a  slight  diarrhea  following  the  accident  which  disappeared 
on  entrance  to  the  hospital.  The  question  was  raised  whether 
the  case  was  one  of  slight  hematomyelia  or  was  pithiatic. 

Suggestive  therapy  was  tried,  and  liquid  was  injected  into 
the  muscles  of  the  lumbar  region  and  the  posterior  surfaces 


shell-shock:  nature  and  causes  345 

of  the  thighs.  In  a  quarter  of  an  hour  the  patient  found  him- 
self able  to  raise  the  foot  above  the  bed.  There  remained  an 
extensor  paralysis  of  the  right  leg.  When  the  patient  was 
made  to  raise  the  foot  he  began  to  show  the  phenomenon  of 
Souques,  called  camptocormia.  He  could  walk,  nevertheless, 
and  took  a  few  steps  sustaining  the  weight  of  his  body  by 
placing  his  arms  on  his  thighs.  Though  he  complained  of 
lumbar  pain,  it  was  finally  possible  for  him  to  pick  up  an 
object  from  the  ground  and  lean  sidewise.  He  could  not, 
however,  stand  up.  Yet  when  the  patient  was  made  to  lie 
down,  his  back  was  spontaneously  straightened.  Treatment 
of  the  camptocormia  was  also  successful. 


346  SHELL-SHOCK:    NATURE   AND   CAUSES 


Astasia-abasia :  Two  cases  from  (a)  thigh  wound, 
and  (b)  shell-shock  and  wound  of  thorax.  Cures 
by  faradism. 


Case  246.     (RoussY  and  Lhermitte,  191 7.) 

An  infantryman  was  wounded  September  23,  1914,  by  a 
bullet  in  the  anterior  and  middle  part  of  the  left  thigh. 
From  the  moment  of  the  trauma,  he  had  not  been  able  to 
walk,  but  gradually  regained  his  ability  to  stand,  and  then  to 
walk.     He  was  returned  to  the  front  (January,  191 5). 

Slightly  wounded  again  in  the  neck,  January  6,  1915,  he 
was  evacuated  and  operated  on.  After  the  operation  he  could 
neither  walk  nor  stand.  His  reflexes  were  normal ;  he  could 
perform  all  movements  when  lying  down,  although  the  move- 
ments were  executed  very  slowly.  As  soon  as  he  could  sit 
upright,  he  was  taken  with  tremors  and  could  not  hold  him- 
self in  a  vertical  standing  position,  nor  take  a  single  step. 
If  he  was  given  crutches,  he  dragged  the  two  legs. 

Under  the  influence  of  electric  treatment  —  a  mild  faradic 
current  —  he  was  cured  at  a  sitting  so  that  he  could  both 
stand  and  walk  (March,  19 16) 

Case  247.     (RoussY  and  Lhermitte,  1917.) 
Astasia-abasia  after  shell  explosion  occurred  in  an  infantry- 
man observed  by  Roussy  and  Lhermitte  at  Villejuif,  July  8, 

1915. 

The   patient   had   been  wounded  September,   19 14.     The 

wound  was  a  superficial  one  in  the  thoracic  wall,  under  the 
right  nipple.  He  had  been  cast  into  a  very  deep  shell  hole, 
but  had  been  able  to  get  back  to  the  aid  station  alone,  taking 
very  short  steps  only. 

As  soon  as  he  reached  the  station,  his  gait  became  spastic, 
trembling  and  hesitant.  Given  two  canes,  he  could  walk 
painfully,  trembling.  At  each  step,  he  would  balance  his 
body  back  and  forth.  He  gave  the  impression  of  a  man 
drawing  some  sort  of  vehicle,  who  had  to  make  a  considerable 
effort  at  each  step. 

The  faradic  treatment  cured  this  patient  at  one  sitting. 


SHELL-SHOCK:    NATURE   AND   CAUSES  347 


War  strain ;  fall  into  water-filled  trench :  Dysbasia, 
tremors,  vasomotor  disorders.  Cure  by  hypnosis. 
Case  to  demonstrate  "  traumatic  "  hysteria  WITH- 
OUT somatic  TRAUMA. 


Case  248.     (NoNNE,  December,  191 5.) 

An  artilleryman  (without  hereditary  or  acquired  neuro- 
pathic taint)  underwent  much  stress  and  strain  in  the  war 
in  Belgium,  Lorraine  and  Flanders.  One  night,  on  leaving 
his  observation  post,  he  fell  into  a  trench  filled  with  water. 
He  felt  pricks  in  the  groin  and  gradually  developed  a  pseudo- 
spastic  tremor  of  the  lower  extremity,  paraparesis  inferior, 
depression,  irritability,  pressure  sensations  in  the  head,  and 
sleeplessness.  He  passed  through  three  hospitals  before 
arriving  at  Hamburg  and  received  the  diagnosis  of  concus- 
sion of  the  brain  and  cord. 

Nonne  found  an  emotional  state  of  depression  with  hypo- 
chondriacal fear,  disturbance  of  sleep,  deficient  appetite, 
constipation  and  pollakisuria.  He  walked  upon  two  crutches, 
dragging  his  legs  inertly  after  him.  There  was  marked  cya- 
nosis, lowered  temperature  and  hyperidrosis  of  the  feet 
and  lower  legs;  exaggeration  of  tendon  and  skin  reflexes 
and  pseudoclonus ;  no  Babinski  or  Oppenheim  reaction. 
There  was  anesthesia  of  the  lower  extremities  and  of  trunk  as 
high  as  the  ribs.  Pulse  130.  Visual  fields  normal.  Sen- 
sory disorders  absent. 

After  the  first  hypnotic  treatment  the  patient  was  able  to 
stand  and  take  a  number  of  steps,  and  the  tremor  gradually 
diminished.  After  two  treatments  standing  became  normal 
and  walking  was  much  improved,  the  tremor  ceased,  cyanosis 
and  hyperidrosis  disappeared,  and  the  movements  of  the 
bowels  and  urination  became  normal.  Thereafter  the  pa- 
tient had  no  attention  paid  to  him  deliberately  and  in  a 
week's  time  became  well. 

Here  is  a  case  in  which,  as  Nonne  states,  the  somatic 
trauma  required  by  Oppenheim  as  the  basis  of  every  trau- 
matic neurosis  did  not  occur.     Moreover,  the  sudden  cures 


348  shell-shock:  nature  and  causes 

by  hypnotism,  or  by  any  other  method  in  these  cases,  war- 
rant us  in  supposing  that  there  are  no  such  fine  molecular 
changes  as  Oppenheim  and  von  Sarbo  assert.  Such  experi- 
ence as  the  cures  in  this  group  of  cases  confirms,  according  to 
Nonne,  the  surprising  result  first  achieved  in  this  war  (Bon- 
hoefTer,  Wagner  von  Jauregg,  Karplus,  Wollenberg,  West- 
phal)  that  the  most  severe  neuroses  produced  by  somatic 
and  psychic  traumata  can  be  cured  in  an  astoundingly  rapid 
manner  without  residuals. 

Re  the  controversy  over  Oppenheim's  traumatic  neurosis, 
Nonne  holds  with  the  Charcot  school  that  traumatic  neuro- 
sis is  clinically  identical  with  hysteria.  Oppenheim  admits 
the  part  played  by  psychogenesis,  but  has  always  laid  a 
greater  emphasis  upon  the  actual  injury  of  the  neuronic 
apparatus  in  which  he  believes.  He  thinks  that  small  hem- 
orrhages, inflammatory  processes,  and  degenerative  proc- 
esses affect  the  neurones  unfavorably,  and  permit  the  psy- 
chogenic effects  to  occur  more  readily.  Of  course  the  in- 
surance-company attitude  and  the  attitude  of  railway  cor- 
porations saw  malingering  in  all  cases,  and  to  this  day, 
neurologists  are  inclined  to  see  a  great  deal  of  "indemnity 
neurosis"  in  these  cases.  Opposed  to  the  corporation  men 
and  the  neurologists  were  the  psychiatrists,  who  chiefly 
upheld  an  emotional  theory  of  genesis  —  whence  we  began 
to  hear  of  the  neuroses  of  fright  and  of  accident. 

Oppenheim  claims  to  have  established  with  war  cases  the 
fact  that  an  entirely  normal  person  without  heredity  and 
without  antebellum  acquired  soil,  may  develop  a  neurosis 
through  war  stress.  Oppenheim  concedes  that  there  may  be 
purely  psychic  cases,  but  holds  that  there  are  nevertheless, 
numerous  purely  physical  cases  and  a  great  number  of  cases 
of  a  compound  nature,  which  are  both  physical  and  psy- 
chical in  their  etiology.  Oppenheim's  point  is  not  that  every 
single  symptom  described  may  not  be  upon  occasion  psycho- 
genic, but  that  the  data  of  this  war  prove  that  neuronic 
injury,  particularly  injury  of  the  peripheral  neurones,  can 
also  produce  these  effects.  Nonne,  Forster,  Lewandowsky, 
and  others,  opposed  Oppenheim's  views  vehemently.  See 
especially  comments  by  Zeehandelaar. 


SHELL-SHOCK:  NATURE  AND  CAUSES        349 


Shell-shock;  BURIAL  HEAD  DOWN:  Brachial 
monoplegia,  head-shaking,  speech  disorder,  corneal 
and  conjunctival  reflexes  absent.  Determination  of 
hysterical  phenomena  to  parts  buried. 


Case  249.     (Arinstein,  191 6.) 

A  Russian  private  was  buried  after  a  shell  explosion, 
September  13,  191 5,  head  down,  so  that  only  his  legs  stuck 
out  of  the  debris.  Afterward  his  right  hand  refused  to  move, 
and  there  was  edema  of  the  right  wrist,  with  pain  referred  to 
the  shoulder  joint.  The  head  shook  and  made  jerky  move- 
ments during  the  day,  but  ceased  them  in  sleep.  Speech  was 
retarded;  words  were  uttered  clearly  enough  but  in  a  sing- 
song fashion;  sometimes  the  man  stammered.  Hearing  was 
diminished  in  the  right  ear.  Pupillary  responses  were  lively, 
but  the  swallowing  reflexes  were  diminished,  and  the  corneal 
and  conjunctival  reflexes  were  absent.  The  tendon  reflexes 
were  lively  on  both  sides.    There  were  no  pathological  reflexes. 

At  the  end  of  October  —  six  weeks  later  —  the  patient 
was  sent  home  on  convalescence  for  three  months,  and  im- 
proved rapidly  after  a  short  time  in  family  surroundings. 
He  was  examined  again,  two  months  after  discharge,  and 
found  normal  in  all  respects.     He  returned  to  the  ranks. 

Re  Shell-shock  in  Russians,  Arinstein  concludes  that  con- 
cussion hysteria  may  occur  in  a  perfectly  normal  person, 
yet  be  innocent  of  all  organic  signs  indicating  destruction  of 
peripheral  or  central  neurones.  Rifle  or  machine-gun  fire 
had  not  in  his  experience  brought  about  concussion  hysteria, 
which  was  invariably  due  to  the  bursting  of  a  large  projectile. 
With  reference  to  Schuster's  remark  that  a  sleeping  man 
never  acquires  hysteria  from  the  bursting  of  a  shell  near  by, 
Arinstein  confirms  Schuster,  finding  amongst  2000  cases 
no  instance  in  a  soldier  sleeping  at  the  time  the  shell  burst. 

Re  effects  of  cannonading,  Gerver  reports  Russian  instances 
of  a  kind  of  hysterical  clavus,  or  sensation  of  a  nail  being 
driven  into  the  back  of  the  head,  in  men  who  have  been  a 
number  of  days  under  stiff  shelling. 


350  SHELL-SHOCK:    NATURE  AND  CAUSES 


Multiple  wounds  and  bullet  wound  of  palm :  ACRO- 
PARALYSIS.     Cure,  five  months. 


Case  250.     (RoussY  AND  Lhermitte,  1917.) 

A  patient  was  observed  at  Villejuif,  February  5,  191 5. 
He  had  been  wounded,  January  2,  1915,  and  showed  scars  of 
a  bayonet  wound  on  the  anterior  surface  of  the  right  thigh, 
of  a  lance  wound  on  the  dorsal  surface  of  the  right  foot,  and 
of  a  bullet  wound  in  the  palm  of  the  left  hand. 

There  was  left  wrist  drop  with  fingers  extended.  On  the 
sensory  side,  there  was  a  glove  anesthesia  and  analgesia  up 
to  the  bend  of  the  elbow.  The  right  leg  showed  a  paresis 
and  contracture,  but  there  were  no  sensory  disorders  in  the 
legs.  Reflexes  were  normal.  The  patient  was  discharged 
cured,  in  May,  1915  (psychoelectric  method). 

This  is  an  example  of  the  so-called  acroparalyses,  paralyses 
limited  to  the  hand  or  foot,  many  of  which  have  developed 
in  this  war,  after  grazing  wounds  or  more  severe  injury. 
More  rarely  they  appear  as  if  spontaneously.  Sometimes 
they  are  preceded  by  slight  arthralgia  or  vague  pains. 

The  condition  in  the  hand  suggests  a  radial  paralysis.  The 
patient  is  unable  to  flex  his  fingers,  though  he  probably  is 
able  to  make  some  movements  with  his  thumb.  Sometimes, 
on  request  to  move  the  hand,  a  series  of  coarse  oscillations 
follows,  somewhat  like  a  tremor.  These  oscillations  are, 
according  to  Roussy  and  Lhermitte,  apparently  pathogno- 
monic, and  depend  upon  the  contraction  of  the  muscles  an- 
tagonistic to  those  whose  movement  has  been  requested. 
These  antagonistic  muscles,  themselves  entirely  incapable 
of  voluntary  movement,  are  seen  to  be  contracting  effec- 
tively and  jerkily  to  meet  the  action  of  the  agonists,  also 
seen  making  jerky  movements.  If  the  forearm  is  moved 
passively  and  rapidly,  the  hand  flops  about  inert,  like  the 
hand  of  a  marionette,  although  not  to  the  degree  of  hypo- 
tonia in  organic  paralysis.  The  hand  is  often  cold,  moist, 
and  cyanotic,  and  even  possibly  analgesic  and  hypesthetic. 


H   • 
en  1^ 


H  S 


O 

*     CI 


en 


SHELL-SHOCK:    NATURE  AND   CAUSES  35 1 


Bullet  wotind  of  ann:  Apparent  radial  paralysis, 
not  resolved  by  self-preservative  swimming  move- 
ments.    Paralysis  actually  hysterical. 


Case  251.     (Chartier,  October,  1915.) 

A  professional  acrobat,  22,  Corporal  in  an  African  Chasseur 
regiment,  was  rather  instructively  tattooed  and  had  appar- 
ently performed  some  of  his  service  in  discipHnary  companies. 
In  short,  one  might  have  a  legitimate  suspicion  of  the  ob- 
jective value  of  any  manifestations  he  might  present.  How- 
ever, one  of  his  chiefs  had  written  a  favorable  letter  concern- 
ing his  services.  He  had  had  various  crises  of  a  hysterical 
character  since  adolescence,  and  there  was  alcoholism  in 
the  family. 

He  was  wounded  May  4,  191 5,  by  a  bullet  which  passed 
through  the  outer  and  lower  part  of  the  right  upper  arm,  and 
thereafter  the  forearm  and  hand  became  completely  inert, 
both  for  flexion  and  extension.  There  was  a  considerable 
hyperesthesia.  The  wound  healed  quickly,  without  compli- 
cations. 

August  5,  about  10  o'clock  at  night,  the  man  —  then  at 
his  depot  —  tried  to  commit  suicide  (motive  not  related  with 
the  war).  He  threw  himself  into  the  Rhone  from  a  height, 
where  the  water  was  deep  and  the  current  rapid.  His 
brother  and  a  comrade,  who  knew  that  he  was  going  to  make 
the  attempt,  saved  him.  Chartier  himself  happened  to  see 
the  whole  scene,  and  noted  that  throughout  the  affair  the 
forearm  and  hand  of  the  patient  remained  inert.  It  seemed 
as  if  there  was  a  radial  paralysis.  This  was  the  more  likely 
as  the  man  had  been  wounded  in  the  arm.  First  care  was 
given.  The  man  had  not  known  of  Chartier's  presence.  He 
had  been  under  water  about  two  minutes. 

From  hospital  he  was  evacuated  three  weeks  later  with  a 
diagnosis  of  radial  paralysis,  coming  on  service  September  11. 
Examination  showed  a  slight  paralysis  of  the  extensors  and 
flexors  of  hand  and  fingers,  and  of  the  hand  muscles.  There 
was  also  a  slight  contracture  of  these  muscles,  more  marked  in 


352  SHELL-SHOCK:    NATURE  AND   CAUSES 

the  flexors.  There  was  pain  upon  reduction,  with  some  jerk- 
ing of  the  muscles.  Electrical  reactions  proved  normal  in 
nerves  and  muscles.  There  was  a  segmentary  anesthesia  to 
pin  prick,  reaching  to  the  level  of  the  elbow;  deep  hyper- 
esthesia of  the  finger  joints.  There  was  no  trophic  or  vaso- 
motor disorder. 

In  short,  here  was  a  case  of  functional  paralysis  with  con- 
tracture of  the  right  hand,  to  be  regarded  as  hysterical  in 
the  classical  sense  of  the  term,  both  by  reason  of  the  anes- 
thesia and  absence  of  trophic  disorder,  and  on  account  of 
the  hysterical  history  of  the  patient.  Functional  reeducative 
treatment  quickly  improved  the  paralysis,  so  that  two  weeks 
later  the  patient  was  able  to  extend  fingers  and  hand.  His 
total  recovery  was  hoped  for,  when,  September  26,  wishing  to 
get  out  of  the  hospital  without  leave,  the  patient  jumped 
from  a  window  and  broke  his  right  leg.  The  functional 
paralysis  of  the  hand  persisted  and  even  grew  more  marked. 

The  interesting  point  in  this  case  is  that  despite  the  power- 
ful nature  of  instinctive  efforts  with  drowning  persons,  this 
patient,  subject  to  an  hysterical  arm  paralysis,  did  not  make 
defensive  movements  with  the  paralyzed  arm;  yet  this  par- 
alysis was  such  as  to  be  greatly  improved  by  psychotherapy. 


shell-shock:  nature  and  causes  353 


Bullet  wound  in  brachial  plexus  region :  SUPINA- 
TOR LONGUS  CONTRACTURE,  hysterical-look- 
ing. Callus  of  fractured  rib  probably  at  fault: 
Treatment  surgical. 


Case  252.     (Leri  and  Roger,  October,  191 5.) 

A  man  was  wounded,  December  21,  1914,  by  a  bullet  which 
entered  about  the  middle  of  the  spinous  process  of  the  left 
scapula  and  was  extracted  a  few  days  later  from  the  pos- 
terior border  of  the  sternocleidomastoid  muscle,  two  finger- 
breadths  from  the  left  clavicle,  that  is,  at  about  Erb's  point. 
The  left  upper  extremity  was  inert  for  ten  days,  but  then 
began  to  move  again,  although  extension  and  flexion  of  the 
fingers  did  not  begin  at  once. 

October,  191 5,  movements  were  normal,  except  those  of 
extension  of  the  forearm,  due  to  contracture  of  the  supinator 
longus  muscle,  a  contracture  that  had  developed  about  three 
weeks  after  the  wound  and  stood  out  along  the  external 
border  of  the  forearm,  almost  suggesting  a  musculotendinous 
retraction.  There  was  a  palpable,  hard  callus  of  a  fractured 
rib,  presumably  a  cause  of  the  permanent  irritation  of  the 
supinator  longus,  being  precisely  at  the  point  where  lesions 
usually  produce  superior  brachial  plexus  palsy. 

Why  should  the  supinator  longus  alone  of  the  Duchenne- 
Erb  group  be  affected?  Perhaps  a  single  root  was  involved  in 
the  irritative  lesion.  The  biceps  showed  also  a  partial  R.  D. 
The  deltoid  was  normal  electrically  and  in  contraction. 

The  treatment  planned  for  this  case  of  isolated  contrac- 
ture of  the  supinator  longus  was  surgical  operation  of  the 
irritative  focus.  According  to  Leri  and  Roger,  it  is  sometimes 
dangerous  to  use  such  measures  as  massage  and  electric 
baths  for  a  paralyzed  limb,  since  the  massage  or  electricity 
excite  not  only  the  affected  muscles,  but  also  the  other  sound 
muscles,  —  muscles  that  are  already  more  powerful  than  the 
paralyzed  muscles  and  may  go  into  antagonistic  contracture. 
Even  in  limited  galvanization,  it  is  desirable  to  work  with 
weak  currents,  so  as  not  to  diffuse  the  current  into  non- 
paralyzed  muscles.     In  case  of  radial  or  sciatic  paralysis, 


354  SHELL-SHOCK:    NATURE  AND  CAUSES 

apparatus  permitting  the  extremities  to  rest  without  over- 
action  of  the  muscles  antagonistic  to  the  paralyzed  ones  may 
well  be  applied. 

We  here  deal  with  a  case,  therefore,  which  looked  purely 
functional,  but  in  which  careful  examination  and  X-ray 
served  to  show  an  organic  focus  of  irritation. 

Re  nerve  concussion,  Tubby  offers  the  following  definition: 
Nerve  concussion  is  damage  to  a  nerve  trunk  without  actual 
destruction  of  the  axis  cylinders.  The  damage  may  consist 
of  an  effusion  of  blood  between  the  nerve  fibres  following 
compression  of  a  nerve  against  the  bone  by  rapid  passage  of 
a  foreign  body  near  the  nerve.  Sometimes,  however,  the 
lesion  which  causes  damage  to  the  nerve  trunk  without 
actual  destruction  to  the  axis  cylinders  is  nothing  more  than 
a  temporary  anemia  or  hyperemia.  In  most  instances,  both 
motor  and  sensory  function  are  together  interfered  with,  but 
in  the  case  of  large  nerve  trunks,  e.g.,  the  popliteal,  there 
may  be  a  separate  concussion  of  motor  or  sensory  bundles. 


SHELL-SHOCK:    NATURE  AND  CAUSES  355 


Contusion  may  effect  a  sort  of  STUPEFACTION  OF 
MUSCLE  and  paralyze  it  by  a  non-psychic  process : 
The  SYNERGY  in  contraction  of  biceps  and  supina- 
tor longus  is  thus  SPLIT.  Biceps  restored  to 
S3mergy  with  the  supinator  by  massage  and  f  aradism. 


Case  233.     (TiNEL,  June,  191 7.) 

A  man  was  wounded  at  about  the  middle  of  his  biceps  and 
three  weeks  later  was  found  to  be  able  to  flex  the  forearm  only 
by  means  of  the  supinator  longus.  The  biceps  remained 
absolutely  flaccid  and  soft,  so  that  the  diagnosis  of  a  lesion 
of  the  musculocutaneous  nerve  (unlikely  as  this  seemed  on 
account  of  the  low  site  of  the  wound)  was  entertained. 

However,  the  biceps  and  the  musculocutaneous  nerve 
proved  electrically  normal.  In  short,  this  paralysis  of  biceps 
was  functional  in  nature.  But,  according  to  Tinel,  there 
could  be  no  voluntary  suggestive  or  hysterical  element  in 
such  a  paralysis,  since  flexion  of  the  forearm  is  normally 
produced  by  a  synergic  contraction  of  biceps  and  supinator 
longus  that  cannot  be  separated  voluntarily. 

Treatment  by  massage  and  rhythmic  faradization  caused 
the  biceps  function  to  return  to  normal,  so  that  voluntary 
synergic  contractions  of  the  biceps  took  place  along  with 
those  of  the  supinator  longus. 

We  here  deal,  according  to  TInel,  with  a  genuine  functional 
paralysis,  nonhysterlcal  —  a  paralysis  due  to  a  kind  of  stupor 
of  the  muscle.  Such  paralyses  due  to  muscular  stupor 
ought  to  get  well  In  a  few  days  or  weeks.  Should  they  per- 
sist, it  Is  clear  that  a  stuporous  paralysis  might  be  transformed 
into  a  hysterical  paralysis.  In  short,  the  direct  contusion  of 
a  muscle  or  group  of  muscles  may  be  the  point  of  departure 
for  various  persistent  paralyses. 


356  shell-shock:  nature  and  causes 


Wound  of  arm:  Blocking  of  impulses  to  certain 
hand  movements.     Recovery  with  splint. 


Case  254.     (Tubby,  January,  1915.) 

A  private  was  wounded  by  a  shell  fragment,  September 
16,  1 914,  and  admitted  to  the  London  General  Hospital, 
September  2"].  A  high- velocity  shell  fragment  had  passed 
through  the  soft  parts  of  the  left  arm  at  a  spot  exactly  cor- 
responding to  the  musculospiral  groove.  He  could  extend 
the  middle  finger  of  the  left  hand,  but  the  other  fingers  were 
held  in  flexion.  The  last  two  phalanges  of  index  finger  could 
not  be  moved,  it  was  found,  on  account  of  severance  of  the 
extensor  tendon  some  years  previously.  Accordingly,  the 
loss  of  function  due  to  the  shell  injury  was  that  of  thumb, 
ring,  and  little  fingers.  Supination  could  not  be  executed 
completely  to  the  extent  of  15  degrees;  there  was  no  R.  D. 
upon  electrical  test,  October  2.  The  sensation  of  affected 
fingers  was  woolly.  November  3,  the  little  finger  had  re- 
covered, but  supination  could  not  be  completely  executed. 

The  treatment  consisted  in  a  bent  malleable  iron  splint, 
with  the  wrist  and  affected  fingers  hyperextended.  No- 
vember 20  all  power  had  returned  with  full  supination,  except 
for  the  two  phalanges  of  index  finger  previously  injured. 

Major  Tubby  thinks  this  a  case  of  physiological  blocking, 
as  from  a  small  hemorrhage  amongst  the  fibers  or  around  the 
nerve. 

Re  inhibition,  Myers  thinks  it  is  the  functional  cause  of  the 
effects  of  shell-shock.  He  thinks  it  is  not  a  fixation  of  the 
idea  of  the  paralysis  of  volition,  but  that  it  is  a  fixation 
of  the  process  of  inhibition  itself  that  produces  the  effects  we 
see  in  Shell-shock.  It  is  a  block  of  ascending  paths  that 
produces  the  anaesthesia  so  characteristic  of  Shell-shock.  It 
is  a  blocking  of  sensory  paths  that  produces  mutism  or 
aphonia.  But  according  to  Myers,  there  is  also  a  block  in 
certain  cases  of  descending  paths  that  control  and  coordi- 
nate various  mechanisms.  The  result  of  a  block  In  the  de- 
scending paths  is  shown  in  spastic,  clonic,  or  ataxic  phenom- 
ena of,  e.g.,  functional  dysarthria.    See  also  Case  253  (Tinel). 


SHELL-SHOCK:    NATURE   AND   CAUSES  357 


Eight  months  of  war  experience  (often  under  heavy 
fire)  without  reaction;  then,  shell-shock;  uncon- 
sciousness :  Right  hemiparesis ;  pain  in  the  left  side 
of  head ;  heat  sensations  of  right  half  of  body ;  dim- 
inution of  hearing  in  left  ear ;  a  variety  of  asymmet- 
rical bilateral  phenomena. 


Case  255.     (Gerver,  1915.) 

A'Russian  private,  24,  sustained  shell-shock  April  14,  1915. 
He  was  observed,  when  the  shell  burst,  to  crouch  down,  and 
then  to  fall  to  the  ground,  unconscious.  The  unconscious- 
ness lasted  about  two  days,  after  which  he  was  found  to  be 
oriented,  though  slow  and  stammering  of  speech,  hardly 
able  to  concentrate  attention  or  sustain  a  conversation,  and 
giving  the  impression  of  a  man  stunned.  There  was  diffi- 
culty in  the  expression  of  thoughts,  and  a  marked  over- 
fatigueability.  After  adding  and  subtracting  accurately  two- 
digit  figures  for  a  time,  the  man  quickly  grew  confused  and 
said  that  trying  to  solve  such  a  problem  made  him  dizzy. 

His  imagination  was  filled  with  gunshots,  shell-bursts,  and 
the  killing  of  comrades,  and  during  any  conversation  the  man 
frequently  shuddered.  Concerning  the  shell-shock,  he  re- 
membered only  that  a  number  of  shells  had  burst  near  him 
and  that  he  came  to  in  the  hospital.  He  kept  looking  to  one 
side  and  to  a  distance,  as  if  listening,  sometimes  bending  his 
head  downwards.  He  would  cry  and  sigh  during  conver- 
sation, and  then  be  quite  unable  to  explain  why.  He  said 
there  were  loud  noises  in  his  ears,  and  that  his  head  and  the 
whole  right  side  of  his  body  felt  hot.  Pain  was  felt  in  the 
left  side  of  the  head.  The  right  hand  and  the  right  foot  were 
weak  (on  distraction,  this  hemiparesis  remained  unaltered). 
Tremors  affected  all  the  extremities.  He  had  a  sensation, 
possibly  hallucinatory,  of  the  creeping  of  insects  on  his  skin. 
The  hearing  of  the  left  ear  was  objectively  diminished. 
There  was  palpitation  of  the  heart  and  difficulty  of  breath- 
ing. Tendency  to  Romberg.  There  was  a  general  hypal- 
gesia,  more  marked  on  the  left  side  of  the  body.     Both  con- 


358  SHELL-SHOCK:    NATURE   AND  CAUSES 

junctival  reflexes  were  diminished.  Knee-jerks  and  Achilles 
jerks  were  exaggerated.  All  the  reflexes  on  the  right  side 
were  livelier  than  on  the  left.  There  was  a  moderate  Babinski 
reaction  on  the  right  side.  Mechanical  over-excitability  of 
muscles.  Dermatographia.  Both  sides  of  the  skull  were  sen- 
sitive on  tapping,  but  especially  the  left  side.  Mannkopf 
sign  on  pressure  of  the  left  side  of  the  cranium. 

Hemorrhagic  points  without  injury  to  the  skin  were  noted 
on  the  skin  of  the  left  hand  and  foot.  Speech  was  stammering. 
There  was  a  marked  digital  tremor,  sometimes  spreading 
to  the  rest  of  the  body  during  examination.  The  muscles 
of  the  face,  eyelids,  and  tongue  showed  sharp  fibrillary  twitch- 
ing. The  pulse  stood  at  lOO  and  frequently  missed  beats. 
Battle  hallucinations,  visual  and  auditory,  sometimes  oc- 
curred, the  commands  of  superiors  and  the  noise  of  guns, 
rifles,  yelling,  and  groans;  the  man  would  see  trenches  or 
redoubts,  or  a  field  full  of  wounded  soldiers  or  attacking 
columns  of  the  enemy.  He  recognized  the  hallucinations  as 
such.  His  sleep  was  troubled  by  nightmares  of  the  same 
general  description. 

For  eight  months  the  man  had  been  in  action  at  the  front, 
under  heavy  gun  and  rifle  fire.  He  was  a  courageous  man, 
who  had  never  felt  fear,  regarding  himself  as  used  to  battle 
and  the  bursting  of  shells.  He  had  not  been  wounded.  The 
entire  situation  seems  to  have  developed  after  the  single  shell 
burst  of  April  14,  1915. 


SHELL-SHOCK:    NATURE  AND   CAUSES  359 


LOCALIZATION  OF  SHELL-SHOCK  SYMP- 
TOMS :  Hemiparesis  and  hemianalgesia  on  side  of 
body  exposed  to  explosion;  contralateral  irritative 
symptoms  of  face  and  tongue. 


Case  256.     (QppENHEiM,  January,  1915.) 

A  soldier  had  a  shell  explode  to  his  right,  October  23, 
1914.  He  declared  that  the  concussion  launched  him  through 
the  air.  When  he  recovered  consciousness  three  hours  later, 
he  lay  in  a  bog  and  was  unable  to  move  either  leg.  Gradual 
improvement  followed.  The  symptoms  were  sensations  of 
formication  in  the  legs,  pain  in  the  back,  blurred  sight, 
hardness  of  hearing,  disturbance  of  speech,  headache,  vertigo, 
weak  memory.     After  a  fortnight  weakness  in  right  arm. 

He  was  admitted  to  hospital  a  week  after  the  injury, 
unable  to  walk,  restless,  given  to  palpitation  and  attacks  of 
anxiety.     On  attempts  to  walk,  leg  spasms  and  tachycardia. 

Transferred  to  nerve  hospital,  December  2.  Sleep  poor, 
uneasy  with  dreams.  Tic  on  left  side  of  face.  On  opening 
the  mouth,  left-sided  faciolingual  spasm.  Paresis  of  right 
arm.  At  first,  right-sided  ankle-clonus  and  paresis  of  leg. 
Knee-jerks  increased.  Speech  hesitating.  Right  hemianal- 
gesia. Concentric  contraction  of  visual  fields.  Tachycardia 
(120).  In  walking  the  right  arm  failed  to  swing  normally. 
Attacks  of  vertigo,  with  falling.  Patient  got  up  at  night  and 
pushed  against  objects  in  his  room. 

There  was  only  slight  improvement  while  under  observa- 
tion. He  became  psychically  more  frank  and  even  talka- 
tive, and  was  moving  more  readily  when  transferred. 

Re  Oppenheim's  conception  of  the  strongly  peripheral  ele- 
ment in  traumatic  neurosis,  he  sums  up  by  saying  that  a 
traumatism  attacking  the  organism  at  its  periphery  is  in 
line  to  produce  a  neurosis  without  any  psychic  mediation 
whatever.  The  role  of  the  psychic  process,  in  Oppenheim's 
view,  is  contributory  to  the  fixation  of  neuroses.  Even  when 
there  is  a  free  interval  betwixt  shell  burst  and  neurosis,  still 
there  are  physical  effects  of  trauma  upon  neurones. 


360  SHELL-SHOCK:    NATURE  AND   CAUSES 


Shell-shock;  unconsciousness;  after  improvement 
in  symptoms  (4  months)  return  to  trenches ;  more 
sjmiptoms  after  5  days:  Sensory  disorders,  espe- 
cially on  left  side  (the  side  more  exposed  to  explo- 
sion) ;  exaggerated  reflexes  on  right  side  with  slight 
clonus  and  with  Babinski  sign.    Improvement. 


Case  257.     (Gerver,  1915.) 

A  Russian  Captain,  45  (heredity  good ;  non-alcoholic,  non- 
syphilitic;  always  in  good  health)  sustained  shell-shock  in  a 
battle  in  southeastern  Prussia,  August  13,  1914,  and  was 
unconscious  for  two  days.  He  was  carried  to  one  of  the 
provisional  field  hospitals,  and  then  evacuated  to  Petrograd, 
where  during  a  period  of  four  months,  he  was  given  electric- 
ity, suggestion,  and  baths.  He  was  feeling  so  much  better 
in  December,  191 4,  that  he  went  back  to  the  front  and  headed 
his  company  in  the  trenches.  He  stood  only  five  days  of 
trench  work,  and  was  sent  for  mental  examination  December 
29,  1914. 

The  captain  was  of  middle  height,  well  developed  but 
poorly  nourished,  of  a  dejected  and  preoccupied  appearance, 
looking  to  one  side  in  conversation,  and  finding  difficulty  in 
the  expression  of  his  thoughts.  He  talked  almost  exclusively 
of  his  illness.  He  found  difficulty  in  adding  or  subtracting 
2-digIt  figures.  He  seemed  to  have  amentia,  frequently  being 
mistaken  as  to  the  most  important  dates  in  his  life.  He  com- 
plained of  general  weakness  and  Inability  to  work.  Any 
endeavor  to  concentrate  caused  vertigo,  irritation,  and  pains 
in  the  head.  Day  and  night  he  was  troubled  about  his  health, 
his  future,  and  his  family's  future.  He  was  going  to  become 
an  invalid  and  a  burden.  He  was  tormented  with  the  idea 
that  people  thought  him  a  simulator.  He  complained  of 
lumbar  pains.  It  seems  that  the  explosion  had  affected  the 
left  side  of  the  body  more  than  the  right  and  he  complained 
more  of  pains  upon  that  side.  In  the  dark  his  gait  was 
unsteady,  and  he  often  had  marked  tremors  of  feet  and 
hands.  In  excitement  the  tremor  would  Increase  uncon- 
trollably.    The  patient  thought  that  his  hearing  was  di- 


SHELL-SHOCK:    NATURE  AND   CAUSES  36 1 

minished,  especially  upon  the  left  side,  and  that  his  left  ear 
was  weaker  than  the  right.  He  slept  poorly  and  had  many 
nightmares;  his  appetite  was  poor,  and  he  was  constipated. 
There  was  difficulty  in  respiration;  the  pupils  were  slightly 
dilated  and  sluggish  in  their  responses.  There  was  a  marked 
tendency  to  Rombergism ;  dermatographia  marked ;  the  skull 
and  especially  the  lumbar  spine  was  painful  on  tapping; 
hyperesthesia  of  the  lumbar  skin;  paresis  of  left  hand  and 
left  foot.  The  tendon  reflexes  were  more  marked  on  the  right 
side  than  on  the  left,  and  there  was  even  a  slight  ankle  and 
patellar  clonus.  The  BabinskI  sign  was  present  on  the  right 
side.  There  were  frequent  fibrillary  contractions  of  the 
muscles  of  the  trunk  and  back. 

Objectively  the  hearing  was  somewhat  decreased  in  the 
left  ear,  and  the  vision  of  the  left  eye  appeared  to  be  somewhat 
impaired  also.  If  the  eyes  had  been  held  closed  for  a  time, 
there  was  difficulty  in  opening  them  quickly.  Aside  from 
a  somewhat  elevated  pulse  and  slight  cardiac  arrhythmia, 
there  was  no  disorder  of  the  internal  organs. 

This  patient  remarkably  improved  but  was  not  absolutely 
well  at  the  date  of  the  report. 

Re  organic  signs  in  Shell-shock  cases,  Oppenheim  warns 
practitioners  and  experts  against  undervaluing  war  neu- 
roses. He  does  not  like  to  have  them  set  down  In  too  off- 
hand a  way,  as  hysteria,  wish-fulfilment,  and  simulation. 
Hysteria  is  not  likely,  according  to  Oppenheim,  In  cases  with 
permanent  cyanosis,  disappearance  of  the  radial  pulse,  tro- 
phic disturbances,  hyperidrosis,  alopecia,  fibrillary  tremors, 
myokymia,  cramps,  dilated  and  sluggish  pupils,  and  weak- 
ening of  tendon  reflexes.  Hyperthyroidism  also  has  been 
found  by  Oppenheim. 


362  SHELL-SHOCK:    NATURE  AND  CAUSES 


Shell-shock,  explosion  on  left  side:  Sensory  dis- 
orders especially  on  left  side;  ecchymosis  of  right 
(uninjured)  leg,  possibly  conditioned  upon  shock 
of  left  hemisphere. 


Case  258.     (Gerver,  1915.) 

An  artillery  officer  had  had  a  shell  burst  to  the  left  side  of 
his  horse,  which  veered  to  the  right  but  did  not  fall.  The 
officer's  left  hand  immediately  became  so  numb  and  weak 
that  he  could  not  hold  his  reins  with  it;  it  shortly  became 
more  painful.  The  left  foot  showed  a  tendency  to  the  same 
anesthesia  and  paresis. 

Curiously  enough,  a  number  of  punctate  hemorrhages 
appeared  on  the  right  thigh  and  lower  leg,  upon  the  outer 
aspect.  According  to  Gerver,  these  hemorrhages  into  the 
skin  of  the  right  leg  may  have  something  to  do  with  a  dis- 
turbance of  circulation  related  with  effects  wrought  upon  the 
left  hemisphere.  During  the  course  of  the  disease,  pains 
occurred  not  only  in  the  left  arm  and  leg  but  also  in  the  right 
leg. 

Re  brain  injuries  produced  by  shell  explosions  without  ex- 
ternal wound,  Roussy  and  Boisseau  have  not  found  a  single 
clinical  instance  amongst  133  cases  observed,  which  sug- 
gested cerebral  softening,  or  even  hemorrhage  into  the  brain 
substance,  the  cord  substance,  or  the  meninges.  These  133 
cases  were  observed  in  army  neurological  centres  and  con- 
tained instances  of  (a)  mental  disease  (confusion,  delirium, 
amnesia),  (b)  nervous  disease  (astasia-abasia,  tremors,  pa- 
ralyses, contracture),  and  (c)  an  intermediary  group  (either 
mental  confusion  with  stupor,  or  hysterical  deaf  mutism). 


SHELL-SHOCK:    NATURE  AND  CAUSES  363 


Shell-shock ;  unconsciousness :  Hysterical  deafness, 
speech-disorder,  gait.  Recovery  by  reeducation. 
Brief  relapse  to  deaf-mutism  at  noise  of  drums. 
Improvement.  Relapse  to  numerous  and  severe 
hysterical  symptoms  at  small  guns  fired  on  King's 
birthday.  Improvement.  Speech  wholly  regained 
in  a  quarrel.    Recovery. 


Case  259.     (Gaupp,  March,  191 5.) 

A  musketeer,  22,  had  been  blind  for  a  time  at  1 1  on  account 
of  some  spinal  cord  disease. 

He  was  a  soldier  up  to  Christmas  eve,  19 14,  when  he  was 
hurled  backward  in  a  trench  in  the  Argonne  by  an  exploding 
hand  grenade.  He  lay  unconscious  for  several  hours,  though 
without  sign  of  physical  injury.  Coming  to  his  senses,  he 
worked  himself  out  of  the  trench  and  crawled  to  another,  but 
again  fell  unconscious.  When  he  awoke  he  was  in  a  physi- 
cian's care  in  quarters,  to  which  he  had  been  taken  by  am- 
bulance men.  Thence  to  the  field  hospital,  and  then  to  a 
private  hospital  at  B. 

Upon  admission,  January  17,  he  was  hard  of  hearing  on 
both  sides,  and  his  speech  was  peculiar:  choked  off  and 
retarded.  His  gait  was  heavy,  on  a  broad  base.  He  was 
subject  to  headaches. 

Exercises  gradually  improved  the  speech  and  the  walking 
disorder  was  quickly  overcome.  February  5  came  a  relapse 
through  fright  at  the  rolling  of  drums  near  by.  Speech  was 
completely  lost,  deafness  set  in,  and  the  patient  ran  restlessly 
to  and  fro  in  tears.  After  a  few  hours  speech  returned  with 
still  some  minor  difficulty. 

From  time  to  time  came  fainting  spells  and  attacks  of 
disorder  of  consciousness,  with  loss  of  orientation  and  the 
idea  of  being  in  the  trench  or  under  cover.  He  would  ask 
whether  it  were  raining  through.  His  mood  herein  was  at 
times  cheerful  and  excited.  Speech  further  improved  from 
the  middle  of  February,  as  well  as  did  the  other  symptoms. 


364  SHELL-SHOCK:    NATURE  AND   CAUSES 

On  the  King's  birthday,  February  25,  occurred  another 
relapse  due  to  his  hearing  small  guns  fired :  Apathetic  stupor, 
clonic  spasm,  aphonia,  abasia,  severe  deafness,  poor  sleep, 
refusal  of  food.  The  next  day  he  was  still  mute,  but  the 
spasms  had  ceased.  He  lay  apathetically  in  bed,  taking  a 
little  liquid  food.  February  27  he  was  still  mute,  though 
more  active,  not  deaf,  getting  up  alone,  walking  unsteadily 
on  a  broad  base,  and  playing  cards  at  the  table.  March  2 
the  word  yes  was  again  enunciated.  March  3  he  talked  more 
freely  and  took  a  short  walk.  March  4  speech  of  a  sudden 
came  completely  back  on  the  occasion  of  getting  excited  in  a 
quarrel  among  some  other  patients.  The  patient  thereafter 
began  to  talk  a  great  deal,  w^as  bright  and  cheerful,  but  still 
complained  of  a  variety  of  nervous  troubles.  Speech  was 
somewhat  difficult,  but  he  was  free  from  any  definite  aphasia 
or  paraphasia. 

i?e  Shell-shock  deafness,  Jones  Phillipson  states  that  con- 
cussion deafness  is  due  to  three  contributory  factors:  (a) 
cerebral  concussion,  {b)  fatigue  (violent  oscillation  of  the 
perilymph,  continued  noises,  strain  of  organ  of  Corti),  and 
(c)  temporary  or  permanent  disorganization  of  the  conductive 
apparatus. 

Re  concussion  deafness,  J.  S.  and  S.  Fraser  found  in  four 
cases  of  actual  explosion  injury,  a  ruptured  drumhead  and 
hemorrhage  into  the  fundus  of  the  internal  meatus  in  three 
cases.  They  did  not  find  evidence  of  neuro-epithelial  changes. 
Possibly  the  fundus  hemorrhages,  besides  giving  rise  to  deaf- 
ness, may  start  up  the  tinnitus  and  giddiness  that  are  some- 
times found.  In  one  case,  there  were  changes  in  the  delicate 
nerve  endings  of  the  auditory  ampullae. 


SHELL-SHOCK:    NATURE   AND   CAUSES  365 


Shell-shock:  Deafness 


Case  260.     (Marriage,  February,  191 7.) 

A  shell  burst  behind  an  English  lieutenant  in  19 14  without 
causing  any  wound  but  making  him  unconscious  for  an  hour. 
During  the  hour  the  Germans  passed  by  and  stripped  him 
of  all  articles  of  value.  He  came  to  and  felt  himself  markedly 
deaf  in  both  ears  with  an  intense  headache.  There  was  no 
hemorrhage,  no  discharge,  no  tinnitus,  no  vertigo.  Four 
days  after  the  shell  burst  he  could  hear  spoken  words  on  each 
side  at  two  feet,  but  could  not  hear  a  watch  that  could 
usually  be  heard  from  3I  to  4  feet.  With  tuning  fork  C  air 
and  bone  conduction  proved  much  subnormal,  though  air 
conduction  was  better  than  bone  conduction.  With  tuning 
fork  C-5  air  conduction  was  subnormal.  Drums  healthy. 
Improvement  followed;  hearing  became  normal  eighteen 
days  after  explosion.  The  treatment  was  rest  in  bed  with 
bromides  early  and  strychnine  later. 

Marriage  states  that  the  psychical  deafness  due  to  shell- 
shock  is  usually  bilateral  and  absolute.  It  is  accompanied 
also,  as  a  rule,  by  other  nervous  signs  and  symptoms,  such 
as  aphonia,  tubular  vision,  paralyses,  and  anesthesias. 
Milligan  and  Westmacott  state  that  the  deafness  is  due  to  a 
functional  suspension  of  neuronic  impulses.  They  regard 
the  brain  as  in  a  state  of  physical  fatigue,  and  the  mind  as  in 
a  state  of  strain.  There  is  no  organic  lesion.  The  neuronic 
impulses  which  are  temporarily  suspended  are  those  which 
run  from  the  higher  cortical  cells  to  the  periphery. 


366  SHELL-SHOCK:    NATURE  AND   CAUSES 


Mine-explosion :    Unconsciousness :    Deaf -mutism. 
Recovery  of  speech  after  epistaxis  and  fever. 


Case  261.     (LiEBAULT,  October,  191 6.) 

A  soldier,  24,  teacher  in  civil  life,  was  in  a  mine  explosion 
November  27,  1914,  at  Vienne-le- Chateau.  He  was  uncon- 
scious six  weeks  and  remembered  nothing  of  what  had  passed. 
They  had  told  him  that  he  had  been  blind  for  a  month.  After 
regaining  consciousness  he  was  a  deaf-mute  and  for  seven 
months  he  did  not  speak.  His  mutism  did  not  bother  him, 
as  he  thought  he  had  always  been  mute.  He  had  always  been 
able  to  write.  He  could  not  remember  what  had  interfered 
with  his  speech  or  tell  whether  he  could  think  the  words 
which  he  could  not  utter. 

May  22,  191 5,  there  was  considerable  nasal  hemorrhage, 
with  fever.  Upon  this  day  he  began  to  speak,  at  first  a  few 
words,  telegram  style,  and  with  aphonia.  A  week  later  his 
voice  returned.  He  was  very  irritable  during  the  period  of 
mutism  and  had  ideas  of  persecution  and  of  suicide  and  com- 
plained of  becoming  easily  fatigued  and  exhausted. 

His  voice,  however,  became  completely  normal  again  and 
his  respiration  better.  On  the  spirometer  he  breathed  four 
liters,  but  still  got  out  of  breath  easily.  His  diaphragmatic 
respiration  was  still  Imperfect.  His  deafness  remained  at 
the  time  of  report  about  as  before,  though  he  had  now  been 
hearing  for  some  time  a  slight  resonance  of  his  own  voice  and 
could  hear  sounds  emitted  a  few  centimeters  from  his  ear. 
At  time  of  report  there  was  still  general  fatigue  with  Insomnia. 

Re  war  deafness,  Castex  states  that  not  merely  shell 
bursts  and  explosions  are  able  to  cause  deafness,  but  the 
din  of  battle  alone.  There  are  two  big  groups  of  war  deaf- 
ness: one  due  to  drum  rupture,  and  the  other  due  to  laby- 
rinthine shock.  Labyrinthine  shock — a  much  more  serious 
matter  — is  produced  when  a  big  shell  bursts.  In  these 
cases,  the  labyrinthine  disorder  is  simply  of  the  same  general 
nature  as  commotio  cerebri.  The  labyrinthine  shock  cases 
often  need  to  be  retired  permanently  from  the  front. 


SHELL-SHOCK:    NATURE  AND   CAUSES  367 


Shell-shock :  Deaf -mutism. 


Case  262.     (MoTT,  January,  1916.) 

A  deaf-mute,  24,  not  of  a  neurotic  temperament  or  of  a 
neuropathic  predisposition,  was  admitted  to  the  Fourth 
London  General  Hospital  November  16,  191 5. 

He  wrote,  "I  left  England  the  8th  of  March,  and  went  to 
Gallipoli  on  the  26th  of  May,  and  about  the  middle  of  August, 
one  of  our  monitors  fired  short.  I  felt  something  go  in  my 
head;  then  I  went  to  the  Canada  Hospital.  They  said  it 
was  concussion."  He  had  seen  the  monitors  firing.  He 
came  to  in  a  dug-out  about  an  hour  afterward.  He  was  quite 
deaf  and  his  head  felt  as  if  it  would  burst. 

He  could  see  and  speak  a  little  but  lost  his  speech  com- 
pletely when  Barany's  tests  were  applied.  The  headache 
then  passed  away,  leaving  the  deaf-mutism.  The  ears,  on 
examination,  proved  normal.  The  patient  was  able  to  cough 
and  whistle.  He  wrote  his  wife  a  letter,  telling  her  how  he 
killed  a  Turkish  woman  sniper,  but  he  did  not  remember  that 
he  had  written  the  letter.  Although  he  said  he  did  not  dream, 
while  asleep  he  would  assume  the  attitude  of  shooting  with  a 
rifle,  as  if  pulling  a  trigger,  and  then  the  attitude  of  using  the 
bayonet:  the  right  parry,  the  left  parry,  and  the  thrust. 
Sometimes  while  asleep  he  would  jump  as  if  a  shell  were 
coming,  and  he  would  catch  his  right  elbow  as  if  hit  there. 
He  would  then  open  his  eyes  wide  and  look  under  the  bed. 
Then  he  would  wake  up  and  begin  to  cry,  but  without  sound. 
Just  such  habitual  attitudes  occur  in  soldiers  under  anesthesia. 
In  hypnotic  sleep,  although  he  trembled  at  his  trench  experi- 
ences, he  did  not  assume  these  defensive  attitudes. 

Mott  states  in  his  Lettsomian  lectures  that  hearing  is 
often  absolutely  lost,  but  that  sometimes  a  man  is  absolutely 
deaf  on  one  side  alone,  either  from  the  ruptured  drum  or 
from  the  violence  with  which  wax  has  been  driven  against 
the  drum.  Mott  speaks  of  the  frequency  of  auditory  hallu- 
cinations, and  of  hyperacusis  — part  of  the  patient's  general 
hypersensitivity  — which  may  increase  the  violence  of  the 
neurosis  and  especially  aggravate  the  headache. 


368  shell-shock:  nature  and  causes 


Shell-shock :  Deaf -mutism ;  convulsions  and  dream. 


Case  263.     (Myers,  September,  1916.) 

A  private,  28,  was  seen  by  Lt.  Col.  Myers  at  a  base  hospital. 
This  deaf-mute  wrote,  "I  was  standing  and  a  shell  bursted 
and  that  is  all  I  can  remember."  This  might  have  happened 
six  days  previously.  The  patient  wrote  vaguely  about  a 
walk  to  "windy  corner";  about  being  billeted  in  a  dug-out, 
a  train  journey,  and  another  hospital.  He  was  deaf,  deficient 
in  sensibility  throughout,  especially  in  the  left  arm  and  left 
side  of  the  face,  and  had  severe  headache.  Two  days  later 
he  started  distinctly  when  hands  were  clapped  while  he  was 
writing,  but  at  the  next  hand-clapping  there  was  no  response. 

After  Lt.  Col.  Myers  wrote  down,  "Imitate  me,"  and  made 
consonant  sounds,  the  patient  succeeded  imitating  them. 
"You  hear  me  a  little  now,"  Lt.  Col.  Myers  wrote.  "Is  this 
the  first  time  you  have  spoken?  "  Patient  replied,  "I  hope 
the  Lord  I  can  get  my  speech."  "But  you  did  speak  just 
now.  Read  this  word.  Say  it."  Whereupon  he  was  got 
to  say  his  name  and  number. 

The  therapy  was  proceeding  properly  when  suddenly  he 
was  seized  with  convulsions,  limb  movements  chiefly  clonic, 
back  arched,  eyes  starting,  later  upturned.  The  patient 
pulled  out  a  crucifix  from  a  locker  near  the  bed  and  regarded 
it  ecstatically  (pulse  85,  corneal  reflexes  preserved).  Three 
minutes  later  there  was  quieting  down,  and  the  patient  was 
induced  to  talk.  He  began  to  talk  about  his  wife.  He  had 
just  been  "seeing  a  farm  and  all  the  fighting."  A  shell  must 
have  come  in  there.  He  had  "seen  the  Lord  Who  saved 
him."  Intense  headache  and  thirst  followed.  According  to 
the  patient  the  excitement  was  due  to  recovery  of  speech. 

He  later  said,  "It  was  just  like  a  dream  when  I  came  to. 
I  was  sweating  awful.  I  was  seeing  the  Lord  while  I  was  in 
the  farm  by  the  Captain.  I  dreamed  that  I  had  the  cross  in 
my  hand  to  meet  him  coming.  I  saw  the  trenches  and  the 
dug-outs  and  the  wife."     In  point  of  fact,  the  Captain  at  the 


SHELL-SHOCK:    NATURE  AND  CAUSES  369 

farm  had  had  his  arm  blown  off,  and  he  had  found  him  lying 
on  the  straw  unconscious.  Under  hypnosis  it  appeared  that 
he  had  gone  to  a  dugout  from  the  farm  and  that  at  the 
clearing  station  he  had  been  "raving,  seeing  things,  shells, 
trenches,  and  things  like  that,  sir."  A  slow  recovery  was 
made  after  evacuation  to  England.  Seven  months  later  he 
returned  to  the  front. 

This  case  appears  to  belong  to  the  B  group  of  mutism 
cases,  according  to  the  classification  of  Myers,  namely, 
to  the  group  in  which  the  effects  are  psychical  rather 
than  physical.  According  to  Myers,  whether  mutism 
occurs  as  an  apparent  result  of  physicochemical  or  oi 
mental  causes  —  that  is,  as  an  A  or  a  B  case  —  it  is 
actually  always  the  result  of  mental  —  that  is,  psycho- 
physiological shock.  Mutism  in  the  A  cases  of  physical 
nature,  where  the  shock  must  have  been  grosser  and 
more  profound,  generally  proves  more  severe  than  in 
the  B  cases.  As  to  the  appearance  of  unconsciousness, 
apparently  confirmed  by  the  patients'  statements  that 
they  "lost  consciousness,"  it  is  a  question  whether  these 
cases  are  not  really  cases  of  deep  stupor.  According 
to  Myers,  the  mutism  is  in  nearly  every  instance 
closely  dependent  on  some  form  of  stupor,  being 
generally  the  relic  of  such  stupor  after  it  has  passed  off. 
Let  the  loss  of  consciousness  be  a  profound  stupor  due 
to  the  lifting  or  burial  of  the  patient,  then  from  this 
stage  there  will  be  a  transition  to  a  state  of  ordinary 
stupor  in  which  intelligence  is  active  but  the  patient 
is  unresponsive  to  stimuli.  The  patient  is  in  a  condi- 
tion called  by  Myers  excommunication,  in  which  the 
inhibitory  process  may  be  regarded  as  protecting  the 
individual  against  further  shock.  As  the  stupor  now 
passes  away,  it  is  natural  that  the  inhibition  should 
appear  lost  in  the  case  of  hearing  and  speech,  which  are 
two  main  channels  of  intercourse  with  others. 

Dumbness  is,  by  far,  the  commonest  disorder  of 
speech,  occurring  in  about  ten  per  cent  of  shock  cases 
in  the  first  thousand  cases  of  shell-shock  seen  by  Lt. 
Col.  Myers.  Stuttering  and  jerky  speech  have  occurred 
in  about  three  per  cent.     Loss  of  voice  is  rarer. 

As  against  the  view  of  Babinski,  that  mutism,  being 
curable^  by  suggestion,  must  have  been  produced  by 
suggestion,  Lt.  Col.  Myers  argues  that  the  stupor  pre- 
ceding mutism  is  the  antithesis  of  suggestibility  and  is, 
in  fact,  a  condition  of  extreme  autofixity. 


370  SHELL-SHOCK:    NATURE  AND   CAUSES 


Naval  gun-fire  effects  on  seaman :  Aphonia.    Two 
recurrences. 


Case  264.     (Blassig,  June,  1915.) 

A  seaman  from  the  Derfflinger  was  brought  into  a  naval 
hospital  with  loss  of  voice,  December  22,  19 14,  able  to  speak 
only  in  a  whisper.  As  a  child  he  had  had  diphtheria,  but 
recovered  without  complication.  He  had  always  had  a  very 
well-controlled  voice.  Early  in  December  he  had  had  a  cold 
owing  to  sentry  deck  duty  in  bad  weather.  Two  days  after 
the  shelling  of  Scarboro,  —  December  16, — while  in  the 
munition  chamber  of  the  big  guns,  he  suddenly  lost  his  voice. 
He  had  been  greatly  upset  during  the  firing  of  the  guns.  In 
two  weeks  he  recovered  speech. 

February  12,  191 5,  he  returned  to  the  hospital  with  a 
complete  aphonia.  This  was  immediately  after  the  naval 
engagement  in  the  North  Sea.  Three  days  later  he  was 
treated  with  electricity  directly  applied  to  the  vocal  cords. 
March  20  he  was  discharged  with  speech  completely  recovered. 
As  soon  as  he  went  on  leave,  however,  his  voice  was  lost  for 
the  third  time,  and  he  was  still  aphonic  at  time  of  report. 


Shell-shock  MUTES  observed,  then  DREAMED 
OF:  MUTISM  developed  the  SECOND  NIGHT 
after  shell  explosion. 


Case  265.     (Mann,  June,  1915.) 

A  volunteer  of  20  was  made  unconscious  for  a  short  time 
by  a  shell  explosion,  but  was  still  fully  able  to  speak  when 
brought  to  the  field  hospital. 

In  the  second  night  after  the  explosion,  however,  he 
dreamed  that  he  had  lost  his  speech.  In  the  ward,  mean- 
time, he  had  seen  a  number  of  shell-shock  mutes.  Following 
this  dream  of  aphasia,  came  several  weeks  of  mutism,  which 
then  cleared  up.  According  to  Mann,  this  is  experimental 
proof  of  the  psychogenic  origin  of  a  mutism. 


shell-shock:  nature  and  causes  371 


Mortar  explosion :  Hysterical  deafness. 


Case  266.  (Lattes  and  Goria,  March,  1917.) 
A  young  soldier,  a  peasant,  fell  down  unconscious  when  a 
mortar  exploded  killing  several  men.  He  regained  con- 
sciousness a  few  hours  later  but  was  deaf  on  both  sides.  He 
looked  dazed  and  did  not  spontaneously  move,  having  to  be 
called  for  meals.  Communicating  by  writing,  he  could  tell 
all  the  details  of  the  accident. 

The  laryngeal  and  corneal  reflexes  were  absent  and  there 
was  a  hyperesthesia  and  hypalgesia  of  the  right  side  of  the 
body.  No  anatomical  basis  for  the  deafness  could  be  deter- 
mined. 


Shell  explosion :  Onomatopoeic  noises  in  ears. 


Case  267.     (Ballet,  1914.) 

A  Zouave  was  with  his  squad  at  Tracy-les-Val  Church, 
October,  1914,  when  the  roof  was  burst  in  by  a  shell  which 
wounded  four  men.  The  Zouave  felt  a  strange  emotion  with 
trembling,  and  whistling  in  his  ears.  However,  he  helped 
his  comrades  into  a  neighboring  car.  From  that  time  for- 
ward, he  was  very  emotional,  and  felt  noises  in  his  ear,  some- 
times humming,  sometimes  whistling.  At  Compiegne  Hos- 
pital a  lumbar  puncture  was  made,  perhaps  with  a  thera- 
peutic purpose,  but  this  gave  no  results.  The  noises  were 
heard  as  a  whistling  pseeee  followed  by  a  boom,  —  an  ono- 
matopoeia recalling  the  whistling  and  bursting  of  the  bomb. 
There  was,  in  short,  no  labyrinthine  lesion,  but  merely  an 
obsessive  mental  phenomenon.  There  were  no  ear  lesions 
objectively.  The  man  developed  a  stuttering  some  time 
after  the  humming  and  whistling  in  the  ear. 


372  SHELL-SHOCK:    NATURE  AND   CAUSES 


Injury  of  eyes  by  gravel  from  shell-burst :   Photo- 
phobia, blespharospasm,   facial  anesthesia,   pains. 


Case  268.     (GiNESTOUS,  January,  191 6.) 

A  soldier  of  the  Ninth  Engineers,  28,  a  Beaux- Arts  student, 
was  wounded,  December  19,  191 5,  by  stones  and  gravel  thrown 
in  his  eyes  by  a  shell-burst.  The  eyelids  swelled  and  the  eyes 
filled  with  tears.  He  was  treated  at  the  relief  station  and 
then  evacuated  to  Verdun.  The  edema  disappeared  in  five 
weeks,  but  it  was  impossible  for  him  to  look  at  light.  Febru- 
ary 2  he  was  evacuated  to  Nice,  where  he  received  the  diag- 
nosis of  traumatic  keratalgia,  blepharospasm,  and  photo- 
phobia. After  eight  days'  leave  he  went  back  to  his  corps; 
but  the  eye  troubles  persisted  and  he  was  sent  to  the  ophthal- 
mological  center  at  Angers,  May  18,  1915. 

Both  his  father,  67,  and  his  mother,  58,  were  irritable  and 
odd.  Three  brothers  and  three  sisters  were  also  more  or  less 
neuropathic,  and  one  of  the  sisters  had  been  in  a  hospital  for 
the  insane  with  a  persecutory  mania.  The  patient  had  a 
daughter,  fourteen  months,  well. 

The  man  was  a  nervous,  impressionable  person,  who  wept 
at  the  slightest  emotion.  With  an  effort  of  will  he  could 
open  his  eyes,  but  if  one  tried  to  open  them  passively  there 
was  stout  resistance.  In  the  dark  the  occlusion  was  not  so 
complete.  Both  eyelids  were  wrinkled  and  folded  and  made 
jerky,  fibrillary  movements.  The  conjunctiva  and  cornea 
were  normal  (fluorescein  test),  but  the  palpebral  conjunctiva 
was  red  and  injected.  The  patient  said  he  had  subcutaneous 
pains  recurring  at  irregular  intervals  above  and  below  the 
left  orbit,  brought  out  or  exaggerated  by  pressure;  but  such 
pressure  had  no  effect  upon  the  lid  movements.  Visual 
acuity  was  normal,  but  the  use  of  ophthalmometer  was 
impossible,  as  was  measurement  of  the  visual  field.  There 
seemed  to  be  no  disorder  of  chromatic  sense.  The  reflexes 
could  not  be  fully  examined;  knee-jerks  preserved.  There 
was  a  zone  of  anesthesia  to  pin  prick,  less  marked  to  heat, 
on  the  whole  left  side  of  the  face.     W.  R.  negative. 


SHELL-SHOCK:    NATURE   AND   CAUSES  373 


Shell-shock ;  burial ;  blow  on  occiput :  Blindness. 


Case  269.     (Greenlees,  February,  1916.) 

A  man  in  the  third  Wiltshire  regiment  was  buried  in  a  shell 
explosion  and  struck  by  a  large  mass  of  earth  on  the  back  of 
the  head.  When  dug  out,  he  was  found  blind.  It  was 
thought  at  the  time  that  the  severe  blow  at  the  back  of  the 
head  had  "concussed  "  the  occipital  cells  for  sight. 

Some  months  later  the  man  was  sent  to  Mr.  Pearson's 
home  for  blind  soldiers  in  London ;  but  two  months  later  was 
returned  to  Weymouth,  under  Greenlees'  charge.  He  thought 
himself  worse,  since  now  he  could  not  see  light  at  all.  He 
had  trained  himself  to  take  care  of  himself  and  steered  con- 
fidently aside  from  obstacles  in  walking  about-  He  was  able 
even  to  learn  the  various  colors  by  the  sense  of  touch,  accord- 
ing to  Greenlees;  thus,  blue  was  diagnosticated  against  red: 
according  to  the  patient,  a  piece  of  colored  card  always  had  a 
rougher  feel  if  it  was  blue  than  if  it  was  red.  In  fact,  his  work 
consisted  of  making  colored  net  bags. 

As  to  the  possible  interpretation  of  such  a  case,  see  Case 
No.         (man  who  could  see  large  letters  sometimes). 

Re  blindness,  H.  Campbell  states  that  the  number  of  cases 
of  hysterical  blindness  appears  to  be  decreasing  as  the  war 
continues.  The  blindness  he  finds  to  be  rarely  an  absolute 
one.  As  a  rule,  the  vision  is  merely  blurred  or  there  Is  a 
contraction  of  the  visual  fields.  The  condition  Is  much  less 
frequent  than  that  of  deaf  mutism. 

Re  hysterical  blindness,  Dieufaloy  is  cited  by  Crouzon  as 
describing  a  triad  of  conditions  characteristic  of  hysterical 
blindness,  namely,  (a)  sudden  onset,  (6)  preservation  of  pupil- 
ary reflexes,  and  (c)  normal  fundus. 


374  SHELL-SHOCK:    NATURE   AND   CAUSES 


Shell-shock  amblyopia  (composite  data). 


Case  270.     (Parsons,  May  1915.) 

Parsons  describes  a  typical  case  of  shell  explosion  ambly- 
opia. After  more  or  less  prolonged  fatigue  from  marching 
and  trench  exposure,  the  soldier  is  knocked  down  or  blown  into 
the  air,  and  more  or  less  severely  injured  or  wounded  by 
concussion,  fracture,  bullets,  or  shell  splinters,  losing  con- 
sciousness, but  perhaps  not  enough  to  prevent  automatic 
walking  in  a  dazed  state  to  the  dressing  station.  Memory 
of  this  phase  is  lost.  The  man  is  instantaneously  stricken 
blind,  possibly  also  deaf;  and  possibly  smell  and  taste  are 
also  lost.  Blepharospasm  is  Intense;  there  Is  lacrlmatlon; 
the  lids  are  opened  with  such  difficulty  that  examination  of 
the  eyes  is  almost  Impossible  (nor,  according  to  Parsons, 
have  the  pupils  yet  been  examined  at  this  stage). 

In  a  week  or  two  the  blepharospasm  diminishes,  and  the 
fundi,  which  are  found  to  be  absolutely  normal,  can  be 
examined.  The  eyes  may  be  found  to  be  quite  normal,  the 
pupils  reactive  to  light  though  perhaps  sluggishly  and  per- 
haps unequally.  Sight  is  now  somewhat  restored,  light  can 
be  perceived,  and  large  objects  distinguished.  The  patient 
can  grope  about  and  usually  does  not  stumble  against  ob- 
stacles. The  fields  of  vision  are  markedly  contracted,  and 
more  so  than  the  avoidance  of  obstacles  in  walking  would 
suggest. 

Vision  is  eventually  recovered  completely.  The  right  eye 
(the  shooting  eye)  Is  often  more  deeply  affected  and  recovers 
more  slowly.  Perhaps  a  central  scotoma  may  persist. 
Sometimes  on  manipulation  of  lenses  the  full  vision  can  be 
produced  for  the  types.  Parsons  seeks  to  explain  the  psy- 
chology of  traumatic  amblyopia  in  the  light  of  deductions  of 
Lloyd  Morgan,  Mark  Baldwin  and  McDougall. 


SHELL-SHOCK:    NATURE   AND   CAUSES  375 


Shell-shock      amblyopia      (excitement,     blinding 
flashes,   fear,    disgust,   fatigue). 


Case  271.     (Pemberton,  May,  1915.) 

Pemberton  calls  attention  to  the  following  factors  in  a  case 
of  amblyopia:  First,  excitement  during  a  prolonged  and  some- 
what critical  attack;  second,  overstimulation  of  eyes  and 
ears  due  to  brilliant  flashes,  night  firing  from  many  batteries 
close  together  (the  gunners  are  always  subject  to  temporary 
deafness  from  this  firing) ;  third,  natural  fear  from  close  burst- 
ing of  shells;  fourth,  disgust  at  decapitated  and  disem- 
boweled soldiers;  fifth,  fatigue  from  twelve  hours'  work. 

The  artillery  sergeant  worked  under  heavy  shell  fire  at 
Gun  No.  I.  A  direct  hit  killed  three  men  serving  No.  2  gun. 
The  sergeant  became  somewhat  excited  but  worked  his  gun 
until  the  following  dawn,  when  he  collapsed  across  one  of  the 
disemboweled  corpses.  He  thus  had  been  at  work  for  about 
twelve  hours.     The  battery  had  fired  400  or  500  rounds. 

A  few  hours  later,  the  man  was  conscious  but  very  feeble 
and  much  shaken.  There  was  amblyopia  and  contraction 
of  the  fields  of  vision  to  rough  tests,  but  no  change  in  color 
vision.  Taste  sense  was  blunted,  and  salt  could  hardly  be 
told  from  powdered  quinin  tablets.  Smell  also  was  practi- 
cally absent,  although  he  had  never  been  able  to  smell 
accurately.  Hearing  was  not  more  affected  than  that  of 
other  men  in  the  battery,  and  there  were  no  tympanic  frac- 
tures. Both  thighs,  from  about  the  apex  of  Scarpa's  triangle 
to  the  knee,  showed  partial  anesthesia,  such  that  a  pin  prick 
that  should  have  been  painful  was  felt  only  as  a  tactile  sen- 
sation, whereas  lighter  stimulation  caused  no  sensation  what- 
ever. The  patient  himself  complained  of  numbness  in  these 
areas.  The  gait  was  slow  and  spastic.  The  knee-jerks  were 
brisk.  Sent  back  to  the  wagon  lines  for  a  week,  the  patient 
lost  his  sensory  disturbance,  but  the  symptoms  of  mental  dis- 
tress Increased.  He  walked  weakly  and  stiffly;  he  continu- 
ally thought  of  the  dead  men  at  the  next  gun,  one  of  whom 
was  a  friend.     He  was  finally  sent  to  a  hospital  in  England. 


376  SHELL-SHOCK:    NATURE   AND   CAUSES 


Shell-shock  amblyopia. 


Case  272.     (Myers,  February,  1915.) 

A  private,  20,  lay  in  the  booking-hall  of  a  station,  October 
28-29,  not  securing  much  sleep;  motored  in  a  bus  next  day 
to  another  place  at  7.30  p.m.;  went  into  billets  at  8  p.m.; 
mounted  guard  10-11.30  p.m.  and  1.45  to  3.45  a.m.;  and 
went  to  the  firing-line  for  the  first  time  at  11  a.m.  October  31. 
The  platoon  advanced  through  two  sets  of  trenches,  which 
were  full,  and  had  to  retire.  About  1.30  p.m.  they  were  found 
by  the  German  artillery. 

This  man  had  been  rather  enjoying  it  and  was  in  the  best 
of  spirits  until  the  shells  began  to  burst.  The  platoon  was 
retiring  over  open  ground.  He  was  kneeHng  on  both  knees, 
trying  to  creep  under  wire  entanglements,  when  two  or  three 
shells  burst  near  by.  Three  more  shells  burst  behind  and 
one  in  front.  The  escape  was  described  by  an  eye-witness 
as  a  miracle.  He  managed  to  get  back  under  the  entangle- 
ments and  into  the  trench,  and  shortly,  as  the  fire  slackened, 
rejoined  his  company. 

His  sight  had  become  blurred  immediately  after  the  shell 
burst.  Opening  his  eyes  hurt  him,  and  the  eyes  burned  when 
closed.  The  right  eye  "caught  it  "  more  than  the  left.  At 
the  same  time,  he  was  seized  with  shivering,  and  cold  sweat 
broke  out,  especially  about  the  loins.  He  thought  the  shell 
behind  caused  the  greater  shock,  like  a  punch  on  the  head 
without  pain.  The  shell  that  burst  in  front  had  cut  his 
haversack  away,  bruised  his  side,  and  burned  his  little  finger. 
This  shell  he  thought  caused  his  blindness. 

He  was  led  to  the  dressing  station  by  two  comrades,  open- 
ing his  eyes  to  see  where  he  was  going  but  finding  everything 
blurred  except  immediately  after  opening  his  eyes.  There 
was  no  diplopia.  Objects  seemed  to  dissolve.  He  was 
weeping  and  worrying  about  becoming  blind.  The  horse 
ambulance  took  him  to  a  hospital  and  thence  to  another 
hospital,  and  thence  he  went  by  motor  ambulance  at  night 
to  the  starting  point,  where  he  arrived  five  days  after  he  had 
entered  the  field.     He  could  remember  nothing  about  the 


SHELL-SHOCK:    NATURE  AND  CATJSES  377 

ambulance  trips.  There  was  a  slight  deafness  which  soon 
passed  off.  In  hospital  he  shivered  almost  incessantly  in 
bed,  and  he  kept  thinking  about  his  experience  and  the  shell 
bursting.  The  shivering  ceased  November  3.  No  micturi- 
tion from  the  afternoon  of  October  30  until  the  afternoon  of 
November  2.  No  movements  of  bowels  from  October  30  to 
November  5. 

It  seems  that  this  soldier  had  been  for  two  months  in  the 
Aisne  district,  sleeping  badly  on  account  of  lumbar  pains  and 
toothache.  There  had  been  albuminuria,  and  the  patient 
said  he  had  failed  to  pass  a  medical  examination.  The  fields 
of  vision  were  found  to  be  distinctly  contracted.  There  was 
difficulty  in  taste  and  smell,  which  the  patient  said  he  had 
lost  since  the  shell-burst. 

Hypnosis  was  tried  but  the  patient  "insisted  on  resisting." 
The  suggestions  were  offered  during  the  concentration 
period.  November  13  taste  and  smell  began  to  return  and 
the  fields  of  vision  were  less  contracted.  He  was  transferred 
to  England  for  further  treatment,  and  by  November  2'j  had 
become  much  improved  and  not  so  "nervy."  February  i  he 
had  begun  to  attend  hospital  as  an  out-patient. 


378  shell-shock:  nature  and  causes 


SHELL  WINDAGE  (NO  EXPLOSION) :   Multiple 
affection  of  cranial  nerves. 


Case  273.     (Pachantoni,  April,  191 7.) 

August  22,  1914,  a  French  officer  was  leading  his  company 
to  an  attack  and  carried  on,  though  wounded  in  the  side  by  a 
bullet.  Suddenly  he  felt  as  if  he  had  received  a  terrible  blow 
with  a  hammer  on  the  left  cheek  and  eye  and  as  if  his  arm 
had  been  torn  off.  He  fell  to  his  knees  without  losing  con- 
sciousness. There  had  been  no  explosion,  and  none  of  his 
soldiers  had  been  hit.  He  felt  of  his  arm  and  carried  his 
hand  to  his  head  to  make  sure  of  the  wounds.  There  were 
none,  but  he  was  bleeding  from  the  nose  and  the  mouth. 
His  left  eye  was  closed  and  his  left  cheek  drawn  "by  an  in- 
visible hand."  His  tongue  had  swollen  until  it  had  to  be 
pushed  out  of  his  mouth.  He  was  breathing  hard.  He  fell 
upon  his  side  without  losing  consciousness  and  he  was  carried 
by  his  men  to  shelter  in  a  trench.  Placed  on  his  back  he  felt 
that  he  could  not  lift  his  head  as  "it  had  become  too  heavy." 
His  voice  was  lost.  He  could  neither  cough  nor  spit.  In 
order  to  get  air  he  had  to  remove  bloody  saliva  from  his 
mouth  with  his  finger.  The  left  side  of  the  head  was  swollen. 
On  opening  his  eyes  he  could  no  longer  see  with  the  left  eye. 
His  cheek  was  covered  with  ecchymoses  but  without  wound. 
A  few  hours  later  he  was  made  prisoner  by  the  Germans. 
For  two  months  he  had  an  increase  of  temperature  every 
evening  and  for  three  months  he  lost  his  voice.  Six  months 
later  there  was  still  visual  impairment.  He  was  anesthetic 
in  the  left  cheek,  unable  to  chew,  paralyzed  in  the  left  facialis 
region.  There  was  alteration  of  taste,  with  atrophy  of  the 
left  side  of  the  tongue  deviating  to  the  paralyzed  side,  and 
nasal  regurgitation.  There  was  continual  drooling  and  con- 
vulsive coughing.  In  dorsal  decubitus  the  head  could  be 
lifted  with  difficulty.  There  was  a  kind  of  paresis  of  the 
esophagus,  as  he  felt  the  bolus  stop  at  the  level  of  the  third 
ribs  so  that  with  each  mouthful  he  had  to  swallow  a  little 
water.     Apparently  he  had  a  paralytic  state  of  the  following 


SHELL-SHOCK:  NATURE  AND  CAUSES         379 

nerves:  optic,  oculomotor,  trigeminal,  glossopharyngeal, 
pneumogastric,  spinal  accessory  and  hypoglossal.  There  was 
evidence  of  a  slight  old  tuberculosis  at  apices.  The  man  was 
slightly  pale.  There  was  an  atrophy  of  the  optic  nerve  and 
some  retinal  swelling.  No  pupillary  reactions  to  light  on  the 
left  side;  but  the  accommodation  reflex  and  sensory  reaction 
were  preserved.  Divergent  strabismus  of  the  left  eye.  The 
taste  on  the  left  side  and  on  the  anterior  part  of  the  tongue 
was  slightly  diminished.  Diminution  of  galvanic  and  faradic 
excitability  on  the  left  side  of  the  face.  No  reaction  of 
degeneration.  Bitter,  salt  and  sweet  tastes  altered.  Left- 
sided  atrophy  of  the  tongue.  No  reaction  of  degeneration 
in  the  tongue  and  thyroid  muscles  although  there  was  a 
marked  diminution  in  faradic  excitability. 

The  author  records  this  case  of  multiple  lesions  of  cranial 
nerves  as  due  to  shell  windage.  Thirty-one  months  after  the 
onset  of  the  paralysis  the  cranial  nerves,  although  manifestly 
regenerated,  had  not  regained  conductivity.  The  officer  was 
examined  by  Pachantoni  at  Loueche-les-Bains  in  Switzerland. 

Re  windage,  see  remarks  under  Case  201, 


<^8o  SHELL-SHOCK:    NATURE  AND  CAUSES 


Wound  of  thigh :  Claudication,  vasomotor  disorder, 
hypothermia,  but  no  exaggeration  of  tendon  re- 
flexes. Under  CHLOROFORM,  ELECTIVE  EX- 
AGGERATION OF  REFLEXES,  i.e.,  in  this  case, 
hyperreflexia  of  affected  thigh,  including  patellar 
clonus,  after  other  reflexes  (including  conjunctival) 
had  become  extinct.  The  case  described  led  to 
the  new  formula  of  THE  PHYSIOPATHIC  SYN- 
DROME   (BABINSKI). 


Case  274.  (Babinski  and  Froment,  1917.) 
Babinski  examined  in  August,  1915,  at  the  Pitie,  a  soldier 
who  had  been  wounded  in  the  upper  and  outer  part  of  the 
thigh.  He  showed  a  most  marked  claudication  with  outward 
rotation  of  the  foot.  There  was  a  muscular  atrophy  of  the 
thigh  but  no  appreciable  disorder  of  the  electrical  reactions. 
There  was  a  slight  limitation  in  the  movements  of  the  hip, 
namely,  the  movements  of  flexion  and  internal  rotation  of 
the  thigh  upon  the  pelvis;  yet  this  limitation  of  movements 
did  not  seem  to  be  in  proportion  to  the  rest  of  the  motor 
disorder.  The  X-ray  showed  no  joint  lesion.  The  right 
knee-jerk  was  a  bit  stronger  than  the  left,  though  this  was 
controversial.  Achilles  reflexes  were  normal  and  equal ;  epi- 
leptold  trepidation  of  the  foot,  and  clonus  of  the  patella 
absent;  the  limb  showed  marked  and  permanent  vasomotor 
disorders  and  local  hypothermia;  both  phenomena  were  of  a 
sharp  and  definite  nature. 

On  the  basis  of  the  intensity  of  these  vasomotor  disorders, 
Babinski  felt  that,  in  accordance  with  his  general  ideas,  he 
was  not  dealing  with  hysteria,  and  that  he  was  in  fact  dealing 
with  the  so-called  physiopathic  syndrome.  Lacking  for  this 
syndrome  was  the  exaggeration  of  the  tendon  reflexes  of  the 
affected  limb.  Might  it  not  be  that  the  improper  attitude 
and  muscular  stiffness  of  the  limb  were  based  simply  on  re- 
tractions of  tendons?  The  patient  was  chloroformed.  This 
procedure  was  the  more  warrantable  as  a  number  of  phy- 
sicians had  thought  of  the  patient  as  an  exaggerator  or 


shell-shock:  nature  and  causes  381 

even  as  a  simulator.  Under  chloroform  there  was  in  fact 
a  slight  tendon  retraction;  yet  on  the  whole  it  was  clear  that 
the  attitude  and  stiffness  of  the  limb  were  largely  dependent 
upon  a  contracture.  When  during  narcosis  all  the  other 
tendon  reflexes  and  skin  reflexes  had  become  extinct,  there 
was  still  to  be  observed  on  the  affected  side  a  hyperreflexia, 
and  even  a  clonus  of  the  patella ;  and  the  clonus  lasted  an 
hour  after  recovery  from  the  anesthetic.  This  curious 
phenomenon  of  elective  exaggeration  of  tendon  reflexes  in 
narcosis,  Babinski  has  observed  to  be  not  infrequent.  It  is 
a  valuable  diagnostic  sign  for  a  sure  proof  of  excess  tendon 
reflexes  in  cases  where  doubt  prevails  under  ordinary  cir- 
cumstances. Sometimes  the  contracture  will  yield,  but  only 
in  the  deepest  sleep,  outlasting  even  the  conjunctival  reflex 
and  the  reactions  to  pricking  of  the  normal  extremities. 
Moreover,  the  contracture  would  return  from  20  to  25  minutes 
before  any  manifestation  of  consciousness.  If  an  endeavor 
was  made  to  reduce  the  contracture  under  full  anesthesia  and 
in  complete  unconsciousness,  a  spasmodic  movement  was 
provoked  which  exaggerated  the  abnormal  attitude  of  the 
limb.  Sometimes  even  the  leg  would  be  thrown  into  flexor 
contracture. 

The  case  above  described  was  the  one  which  led  Babinski 
to  his  new  formula  of  the  Physiopathic  Syndrome.  This 
he  describes  in  general  terms  as  follows: 

These  disorders  consist  in  post-traumatic  contractures, 
paralyses  or  paretic  states,  but  are  not  attended  by  any  of 
the  signs  of  the  so-called  organic  diseases,  either  of  lesions  of 
the  central  nervous  system,  or  of  the  peripheral  nervous 
system,  or  of  the  great  arterial  systems.  In  fact,  these  dis- 
orders somewhat  resemble  hysterical  manifestations.  The 
underlying  lesions  appear  to  be  sometimes  extremely  small; 
in  fact,  so  minimal  as  to  be  out  of  proportion  with  the  func- 
tional disorders  that  they  produce.  These  disorders  do  not 
correspond  with  any  known  anatomical  regions,  but  they  are 
singularly  tenacious,  and,  unlike  truly  hysterical  (pithiatic) 
phenomena,  they  are  completely  resistant  to  suggestion.  Yet 
it  is  not  merely  in  resistance  to  suggestive  therapy  that 
these  reflex  disorders  differ  from  hysteria;  for  besides  the 


382  shell-shock:  nature  and  causes 

contracture  and  the  paralysis  or  paresis  found  in  the  different 
segments  of  the  extremity  concerned,  the  complete  Babinski 
syndrome  includes  also  muscular  atrophy,  exaggeration  of 
tendon  reflexes,  alterations  of  skin  reflexes  (even  amounting 
to  areflexia),  hypotonia,  mechanical  over-excitability  of  the 
muscles  with  retardation  of  the  muscular  contraction; 
quantitative  changes  in  electrical  excitability  of  muscles 
(excess  or  diminution  without  R.  D.),  mechanical  over- 
excitability,  and  occasionally  electrical  over-excitability  of 
the  nerv^es,  disturbances  in  objective  and  subjective  sensi- 
bilities (anesthesia  and  pains),  heat  regulation  disorders 
(especially  hyperthermia),  and  disorder  of  the  vasomotors 
(cyanosis,  skin  redness,  oscillometric  lowering  at  the  periph- 
ery of  the  extremity  in  the  presence  of  low  temperature), 
secretory  disorders,  and  various  trophic  disorders  of  the  bony 
system,  the  skin,  and  the  nails. 

Despite  the  permutations  and  combinations  of  these 
symptoms,  according  to  Babinski  they  amount  to  a  new 
group  of  disorders  and  represent  a  nosological  species:  a 
species  of  disease  phenomena  that  lies  midway  between  the 
organic  affections  and  hysterical  disorders.  Babinski  pro- 
poses the  term  physiopathic  for  these  phenomena,  a  term 
which  excludes  the  connotation  of  hysteria  and  all  forms  of 
psychopathia,  on  the  one  hand,  and  seems,  on  the  other,  to 
express  the  fact  of  their  correspondence  to  a  physical  material 
perturbation  in  the  nervous  system  of  a  novel  sort. 


SHELL-SHOCK:    NATURE   AND   CAUSES  383 


Bullet  wound  of  ankle :  Contracture  effect  of  chloro- 
form. 


Case  275.  (Babinski  and  Froment,  191 7.) 
A  man  was  wounded,  September  i,  19 14,  by  a  bullet  in  the 
left  ankle.  Contracture  of  the  foot  and  of  the  four  outer  toes 
in  extension  followed,  with  a  flaccid  paralysis  of  the  great  toe. 
The  left  knee-jerk  was  a  little  stronger  than  the  right;  the 
left  Achilles  jerk  also  appeared  weaker  but  observation  was 
difficult  on  account  of  contracture  of  the  foot. 

Chloroformed,  October  22,  191 5:  There  was  no  sharply 
defined  asymmetry  of  the  tendon  reflexes.  The  left  Achilles 
reflex  appeared  a  little  weaker.  In  the  phase  of  muscular 
resolution,  the  contracture  disappeared  entirely,  but  it  re- 
appeared a  little  after  the  return  of  the  tendon  reflexes.  The 
reappearance  of  the  contracture  preceded  the  reappearance 
of  consciousness  from  twenty  to  twenty-five  minutes. 


384  shell-shock:  nature  and  causes 


Post-typhoidal  reflex  or  physiopathic   disorder  of 
right  leg.     Elective  exaggeration  under  chloroform. 


Case  276.     (Babinski  and  Froment,  191 7.) 

A  typhoid  patient,  October  20,  19 14,  showed  phlebitis  and 
abscess  of  the  right  buttock  with  contracture  of  pelvic  tro- 
chanteric muscles.  He  was  sent  to  the  Pitie  on  medicolegal 
grounds. 

September  22  there  was  found  a  slight  laxity  of  the  patella 
tendon,  as  well  marked  on  the  left  side  as  on  the  right.  The 
right  side  was  more  cyanotic,  due  to  the  inactivity  of  the  limb. 
There  was  no  edema.  Tendon  and  skin  reflexes  were  normal. 
The  lack  of  power  was  diagnosticated  as  purely  functional, 
and  the  report  was  rendered  that  the  soldier  could  begin  to 
walk  as  soon  as  he  desired.  The  two  knee-jerks  were  noted 
to  be  stronger  and  polykinetic,  and  the  right  knee-jerk  ap- 
peared a  little  stronger. 

The  patient  was  chloroformed,  October  25,  191 5.  Almost 
immediately,  the  knee-jerks,  Achilles  jerks,  plantar,  and 
cremasteric  reflexes  disappeared.  During  the  first  period  of 
anesthesia,  there  was  no  accentuation  of  the  reflexes,  but  at 
the  beginning  of  recovery  the  anticipated  reappearance  of 
the  right  knee-jerk  was  observed.  This  knee-jerk  was  already 
sharply  defined  at  a  moment  when  the  left  knee-jerk  was  still 
abolished.  In  a  later  phase  of  recovery,  the  right  knee-jerk 
was  very  markedly  exaggerated  and  a  patellar  clonus  was 
demonstrable  on  the  right  side.  Even  percussion  of  the  left 
patellar  tendon  brought  about  a  contraction  of  the  right 
adductors.  There  was  a  true  clonic  and  tonic  spasm  of  these 
muscles.  On  the  other  hand,  percussion  of  the  right  patellar 
tendon  was  able  to  provoke  no  contraction  of  either  right  or 
left  adductors.     Nor  was  there  at  any  time  any  ankle  clonus. 


SHELL-SHOCK:    NATURE  AND   CAUSES  385 


Hysterical  lameness  (bullet  wound  of  calf)  cured, 
but  the  associated  ''reflex "  disorder  (in  the  sense  of 
Babinski  and  Froment)  NOT  cured. 


Case  277.     (Vincent,  April,  191 6.) 

A  corporal  was  wounded  by  a  bullet  in  the  calf,  September 
8,  1914.  At  the  end  of  July,  1915,  his  lameness  continued  and 
he  disliked  to  lean  on  his  left  leg  which  bent  under  him.  There 
was  a  slight  atrophy  of  the  left  calf.  The  lower  leg  could  not 
be  extended  upon  the  thigh  if  the  foot  was  in  dorsal  flexion, 
and  the  dorsal  flexion  of  the  foot  was  itself  limited.  There 
were  no  reflex,  vasomotor  or  electrical  disorders.  The  man 
was  given  the  usual  treatment  by  Vincent  and  soon  learned 
to  carry  his  body  on  either  foot,  and,  being  well  disposed, 
speedily  abandoned  his  lameness,  acquiring  such  skill  in 
movements  that  he  became  monitor  over  the  other  soldiers, 
watching  over  them  in  his  capacity  as  corporal. 

For  about  a  year  he  thus  served  as  monitor,  and  when  fully 
cressed  did  not  seem  abnormal  or  look  as  if  he  were  walking 
lame.  However,  after  walking,  say  6  kilometers,  rapidly,  he 
dragged  his  leg;  nor  was  extension  of  the  lower  leg  upon  the 
thigh  absolutely  complete  in  habitual  walking,  though  he  was 
able  to  extend  perfectly  if  requested.  Dorsal  flexion  of  the 
foot  was  also  still  somewhat  limited,  and  the  measurements 
of  the  two  lower  extremities  at  both  calf  and  thigh  showed  a 
persistent  slight  atrophy  on  the  left  side.  He  was  then  sent 
into  the  auxiliary  service  and  did  good  work  as  draughtsman. 
In  the  winter  the  left  foot  got  cold  rather  easily. 

This  case  is  instanced  by  Vincent  to  support  the  contentions 
of  Babinski  and  Froment  that  the  truly  "  physiopathic  "  or 
"reflex  "  disorders  do  not  completely  clear  up  in  the  recovery 
from -the  associated  hysterical  disorders.  That  limb,  which  is 
the  seat  of  physiopathic  disorder,  is  not  in  a  state  of  meio- 
pragia. 


386  SHELL-SHOCK:    NATURE  AND   CAUSES 


Foot  trauma :  Pains  and  dysbasia,  hysterical ;  slight 
atrophy  of  calf,  physiopathic.  Differential  dis- 
appearance of  hysterical  symptoms ;  increase  of  phy- 
siopathic symptoms. 


Case  278.     (Vincent,  April,  1917.) 

Cloves  Vincent  examined  a  man  who  had  been  wounded  in 
the  foot  but  without  injury  to  the  bones.  He  was  first 
examined  in  July,  191 5,  when  he  complained  of  foot  pains  and 
was  walking  with  crutches.  The  left  calf  was  smaller  than 
the  right  (4  cm.).  The  tendon  reflexes  were  normal.  There 
was  no  abnormality  of  electrical  reaction.  There  was  no 
proportionality  between  the  trouble  with  walking  and  the 
organic  status.  A  large  part  of  the  trouble  appeared  to  be 
hysterical.  In  fact,  upon  treatment,  the  man  was  soon  able 
to  abandon  the  crutches  and  to  walk,  though  lamely.  He 
was  put  into  the  auxiliary  military  service. 

However,  the  pains  grew  more  marked  and  the  lameness 
increased.  Incapable  of  working,  the  patient  was  sent  to 
the  neurological  center  at  Montpellier,  whence  he  came  to  the 
neurological  center  at  Tours  in  September,  191 6.  He  had 
never  been  confined  to  bed,  and  had  never  ceased  his  daily 
walking,  aided  by  a  cane.  The  walking  disorder  was  very 
pronounced.  The  patient  said  he  was  still  suffering  much. 
The  difference  between  the  two  calves  was  now  8  cm.  and  the 
thigh  was  atrophied,  though  the  atrophy  had  been  absent  in 
July,  1 91 5.  There  was  hyperexcitability  of  leg  muscles. 
The  right  foot  was  colder  than  the  left.  The  hysterical  phe- 
nomena, so  pronounced  in  July,  191 5,  were  now  absent,  yet 
the  reflex  phenomena  were  sufficient  to  invalid  the  man. 


SHELL-SHOCK:    NATURE  AND  CAUSES  387 


Shell-shock  paraplegia  may  AFTER  TWENTY 
MONTHS  develop  vasomotor  and  secretory  dis- 
orders :  The  whole  to  vanish  on  treatment. 


Case  279.     (RoussY,  April,  191 7.) 

A  foot  chasseur,  22,  a  farmer  in  civil  life,  sustained  shell- 
shock  cL  distance,  June  2,  1915.  He  had  no  wound,  but  losii 
consciousness.  He  was  evacuated  for  "contusion  of  back" 
to  a  hospital  June  4  to  12;  for  "contusion  of  back  and  com- 
motio cerebri''  to  Portarlier,  to  July  21;  for  "internal  con- 
tusions and  commotio  cerebri  "  to  Besangon,  where  he  was 
in  three  hospitals  up  to  May  31,  1916,  and  the  diagnosis 
"hysteria,  old  commotio  cerebri  and  trepidant  astasia- 
abasia  "  was  rendered  and  psychotherapy  tried.  The  man 
was  then  evacuated  to  Saint  Ferreol  and  the  diagnosis  "hys- 
terical paraplegia "  rendered.  He  finally  reached  Veil- 
Picard  in  February,  191 7,  still  victim  of  paraplegia. 

Up  to  this  point  there  had  been  no  signs  suggestive  of 
organic  lesion  of  the  spinal  cord  or  any  hysteroorganic  inti- 
mation whatever.  But  in  February,  1917,  besides  the  motor 
disorder  there  was  a  hypothermia  of  several  degrees,  with 
cyanosis  and  hyperidrosis  of  both  feet,  with  a  marked  dim- 
inution (and  absence  on  one  side)  of  the  plantar  cutaneous 
reflexes.  The  man  was  also  victim  of  "hysterical  pregnancy." 
The  cyanosis,  hypothermia  and  hyperidrosis  lasted  six  weeks. 

March  23  the  man  was  given  treatment  and  for  the  first 
time  in  21  months  was  able  to  stand  and  walk.  The  foot 
now  turned  from  blue  to  red,  and  instead  of  cold  became 
warm,  even  hot.  In  about  a  week  the  hyperthermia  di- 
minished, and,  with  the  other  troubles,  disappeared.  There 
remained  only  a  slight  swelling  of  the  foot  and  ankle  joints, 
due  to  the  painful  exercises  given  the  patient. 

It  would  seem,  then,  that  a  hysterical  paraplegia  of  long 
duration  may  finally  associate  itself  with  marked  vasomotor 
and  secretory  disorders  and  that  these  may  be  altered  with 
extreme  rapidity  on  the  very  day  in  which  the  hysterical 
phenomena  are  removed,  and  quite  disappear  in  a  fortnight. 


388  shell-shock:   nature  and  causes 


TETANUS  clinically  cured :  Phenomena  in  part  re- 
produced UNDER  CHLOROFORM  ANESTHE- 
SIA five  weeks  afterward. 


Case  280.     (MoNiER-ViNARD,  July,  191 7.) 

An  Infantryman,  wounded  at  Notre  Dame  de  Lorette,  May 
9,  1915,  by  a  shell  fragment  in  the  right  popliteal  space,  was 
given  a  preventive  injection  of  5  c.c.  of  antitetanic  serum, 
evacuated  to  a  hospital,  May  12,  and  developed  signs  of 
tetanus  August  i,  with  trismus  and  pains  and  spasms  in  the 
right  leg. 

The  disease  progressed  with  dysphagia,  stiffness  and  par- 
oxysmal hypertonia  of  the  legs,  especially  of  the  right  leg, 
fixed  orthotonus  of  the  trunk,  neck  hyperextended,  arms  stiff 
but  able  to  move.  Antitetanic  serum  was  given  daily.  At 
the  end  of  eight  days  there  was  a  marked  improvement  and 
the  whole  course  ran  to  approximate  recovery  in  25  days  from 
the  onset  of  tetanic  symptoms,  at  which  time  the  man  was 
able  to  get  up  and  walk  on  a  crutch.  The  external  popliteal 
nerve  had  been  sectioned,  and  the  foot  was  in  a  marked 
equinovarus. 

Chloroform  was  administered  for  the  purpose  of  straighten- 
ing the  foot,  September  2,  that  is,  about  five  weeks  after  the 
apparent  end  of  the  tetanus.  The  first  stage  of  the  anesthesia 
lasted  about  two  minutes,  but  at  this  point  the  trunk  and  leg 
muscles  passed  into  a  state  of  diffuse  contracture.  In  fact, 
a  tetanic  syndrome  took  place  in  the  midst  of  the  anesthesia. 
At  a  time  when  the  corneal  reflex  was  completely  abolished, 
it  was  still  impossible,  with  the  exertion  of  the  greatest 
strength,  to  flex  the  segments  of  the  lower  extremities. 
Moreover,  the  trunk  was  stiffly  extended  and  the  jaws  were  in 
trismus.  Tonic  and  clonic  contractions  were  produced  by  the 
efforts  made  to  straighten  the  foot,  and  these  contractions 
passed  from  the  right  side  to  the  left.  The  chloroform  was 
now  increased  and  a  transient  resolution  of  the  muscles  was 
obtained,  lasting  hardly  more  than  a  half  minute.  As  all 
efforts  to  reduce  the  pedal  deformity  failed,  anesthesia  was 


shell-shock:  nature  and  causes  389 

stopped.  The  contractures  and  paroxysms  lasted  a  few 
minutes.  The  knee-jerks  were  extremely  exaggerated  and 
there  was  a  bilateral  ankle  clonus.  After  a  brief  phase  of 
excitement,  the  patient  emerged  from  anesthesia,  began  to 
talk  with  his  comrades,  and  ate  his  usual  meal  without  in- 
convenience. The  chloroform  anesthesia  had  lasted  twenty 
minutes,  and  60  grams  had  been  administered. 

It  was  now  determined  to  section  the  tendo  Achilles  and 
the  tibialis  posticus.  September  8  the  man  was  chloro- 
formed again  and  the  same  phenomena  were  exactly  repro- 
duced. Sixty  grams  of  chloroform  was  again  administered. 
The  tendon  resections  permitted  placing  the  foot  in  the  proper 
attitude.  Next  day  the  patient  was  examined  neurologl- 
cally.  The  skin  reflexes  were  found  normal.  The  Achilles 
and  knee-jerks  were  somewhat  exaggerated,  but  equal  on  the 
two  sides.  There  was  no  ankle  clonus.  Sensations  proved 
normal.  There  was  a  mechanical  hyperexcltabllity  of  the 
muscles  of  the  anterior  aspect  of  the  thighs  and  of  the  calf. 

In  another  case  chloroformed  17  months  after  recovery 
from  tetanus  no  such  phenomena  appeared.  It  would 
seem  that  the  impregnation  with  tetanic  virus  or  toxin  must 
last  in  the  nervous  system  a  good  deal  longer  than  the  appar- 
ent disease  clinically  lasts,  but  that  this  belated  and  con- 
cealed Intoxication  eventually  passes. 

The  phenomena  are  perhaps  analogous  to  those  of  Bahin- 
ski  and  Fromenfs  so-called  post-traumatic  physiopathic  or 
refiex  phenomena.  It  was  following  the  special  work  of 
BabinskI  and  Froment  upon  the  use  of  chloroform  anes- 
thesia In  detecting  physiopathic  conditions  that  Monier- 
Vinard  made  his  observations  In  cases  of  tetanus. 


390  SHELL-SHOCK:    NATURE  AND   CAUSES 


Shell-shock  from  falling  of  shell  at  a  distance: 
Hysterical  hemiplegia,  terminating  in  brachial  mono- 
plegia. Case  to  show  that  the  reflex  or  physiopathic 
disorders  of  Babinski  and  Froment  may  occur  with- 
out mechanical  injury  in  the  region  involved. 


Case  281.     (Ferrand,  June,  1917.) 

A  soldier  of  the  class  of  191 7  who  never  went  to  the  front, 
while  in  training  at  Belfort,  felt  violent  emotion  on  the  occa- 
sion of  the  falling  of  a  big  shell  in  the  town  of  Belfort.     The 
explosion  was  a  good  distance  from  him.     He  lost  conscious- 
ness a  few  moments,  February  23,  191 7,  and  almost  at  once 
found  himself  unable  to  move  his  left  side.     He  was  hemi- 
plegic   three   months,   but   his   leg  shortly  regained   power. 
December  23  he  entered  a  neurological  center  with  his  arm 
flaccid  and  a  paralysis  affecting  the  shoulder  also.     There 
was  an  almost  complete  anesthesia  of  the  cirm  terminating  in 
segmentary  fashion  about  the  shoulder,  and  the  whole  of 
the   left  side  was  slightly  hypesthetic,  although  there  was  no 
disorder  of  motion  except  in  the  arm.     The  tendon  reflexes 
of  the  left  arm  were  exaggerated,  and  there  was  even  con- 
tracture upon  percussion  of  the  muscles  themselves.     Per- 
cussion of  the  thenar  and  hypothenar  eminences  produced 
movements   of   the   hand.     There   were   several   vasomotor 
disorders.     Percussion  led  to  large  vasomotor  plaques,  and 
rubbing  of  the  skin  produced  a  reddening  which  passed  away 
slowly.     The  hand  was  red  and  cold.     Slight  electrical  hyper- 
excitability  of  flexors  with  feeble  galvanic  current ;  excitation 
of  the  extensors  not  associated  with  any  contractions  of  the 
antagonist    muscles.      Threshold    lower   for    flexors   on   the 
affected  side  in  the  forearm.     Half  centimeter  atrophy  of  the 
biceps.     The  forearm  and  hand  were  possibly   slightly  in- 
creased in  volume  from  a  blue  edema  of  the  dorsal  surfaces. 
The  man  was  very  timid,  complained  little,  and  accepted  all 
treatment,  which,  however,  was  not  very  effective.     This  is 
presented  by  Ferrand  as  a  case  with  physiopathic  disorder 
in  the  sense  of  Babinski  and   Froment,  though  it  does  not 
present  any  sign  of  organic  lesion  whatever. 


SHELL-SHOCK:    NATURE   AND   CAUSES  39I 


Shell  fire:   Delayed   shell-shock   symptoms,   sub- 
lethal, appearing  in  England. 


Case  282.        (McWalter,  April,  1916.) 

A  soldier  was  picked  up  insensible  in  the  public  street  and 
brought  to  hospital  by  ambulance,  unconscious,  breathing 
stertorously,  pupils  dilated,  lips  parched,  unresponsive  to 
stimuli,  but  without  signs  of  injury  or  alcoholism. 

The  pulse  grew  slower,  the  respirations  more  sighing,  the 
heart-beat  more  diffused  and  labored;  but  towards  evening, 
about  eight  hours  after  admission,  he  began  to  move  the 
eyelids  and  lips,  and  muttered  a  response  to  the  request  for 
his  name.  After  ten  more  hours,  respiration  grew  better, 
and  Croton  oil  led  to  a  movement  of  the  bowels.  Natural 
sleep  intervened,  and  18  hours  after  the  onset  of  unconscious- 
ness, the  man  woke  up,  and  in  the  course  of  a  few  days 
became  fairly  well  though  still  dazed  and  confused. 

This  soldier  had  never  received  any  definite  injury  in  his 
war  service,  but  McWalter  attributes  his  break-down  to  the 
effects  of  the  constant  shocks  from  the  bursting  of  shells,  and 
the  scattering  of  shrapnel. 

McWalter  generalizes  that  a  soldier,  in  the  course  of  some 
civil  occupation  after  the  war,  might  develop  symptoms,  even 
fatal  symptoms,  and  still  the  death  in  the  case  would  be  a 
direct  consequence  of  the  war. 


392  SHELL-SHOCK:    NATURE   AND   CAUSES 


Shell-shock  symptoms,  some  initial,  with  recovery — 
others  late  and  gradual,  with  deterioration. 


Case  283.     (Smyly,  April,  191 7.) 

A  soldier  became  blind,  deaf  and  dumb,  as  well  as  paralyzed, 
as  a  result  of  shell  explosion.  When  he  arrived  at  the  hospi- 
tal, he  was  able  to  see  but  had  visual  hallucinations.  In  a 
few  days  he  recovered  his  hearing.  There  was  a  fine  tremor 
of  the  hands,  controllable  by  suggestion.  There  was  an 
almost  complete  amnesia,  but  the  patient  remained  able  to 
read  and  write. 

The  pain  persisted  several  months.  The  patient  was 
physically  well  and  seemed  perfectly  Intelligent  despite  his 
aphasia  and  amnesia.  One  night,  he  sprang  out  of  bed,  shout- 
ing, "The  guns  are  coming  over  us!"  and  from  that  time 
forward  was  able  to  speak.  Amnesia,  however,  supervened 
for  the  months  in  the  Dublin  Hospital,  and  the  patient 
believed  that  he  was  still  in  France.  He  also  became  unable 
to  read  or  write,  and  was  unable  to  recognize  any  letters 
except  those  he  had  been  taught  to  speak  during  his  period 
of  dumbness.  Stil  later  he  got  a  flaccid  paralysis  of  the  legs. 
From  seeming  perfectly  intelligent,  he  began  to  seem  markedly 
deteriorated.  Hypnosis  with  waking  suggestions  had  no 
power  upon  him.  After  a  time,  intelligence  reappeared,  but 
there  had  not  been  any  recovery  of  locomotion  at  the  time 
of  report. 


shell-shock:  nature  and  causes  393 


Wounds,  gas,  burial :  Collapse  on  home  leave. 


Case  284.     (E.  Smith,  June,  1916.) 

A  non-commissioned  officer  went  through  the  first  eleven 
months  of  the  war  in  France  and  Flanders  and  was  subjected 
to  every  kind  of  strain  therein.  He  was  wounded  twice, 
gassed  twice,  and  buried  under  a  house,  in  each  instance  being 
treated  in  the  field  ambulance  and  returning  to  the  trenches. 
Some  time  thereafter  he  was  granted  five  days'  leave. 

On  reaching  home,  while  waiting  for  a  train,  the  officer 
suddenly  collapsed  and  became  unconscious.  For  months 
thereafter,  he  was  the  subject  of  a  severe  neurasthenia;  "the 
whole  of  his  trouble  seemed  to  be  due  to  the  dread,  lest  on  his 
return  to  the  front,  the  added  responsibilities  which  would 
fall  upon  his  shoulders  might  be  too  much  for  him."  He 
thought  his  intelligence  had  been  numbed  by  his  experience. 
He  thought  his  memory  was  unreliable,  and  that  he  could 
understand  neither  complex  orders  nor  even  the  newspapers. 

As  to  the  reason  for  his  maintenance  of  composure  at  the 
front,  this  may  be  laid  to  the  excitement,  the  officer's  sense 
of  responsibility,  and  the  example  he  felt  he  should  set  his 
men.  This  kind  of  case  "demands  a  great  deal  of  patient 
and  sympathetic  attention  before  the  real  cause  is  elicited, 
and  then  months  of  daily  reeducation  to  build  up  anew  the 
man's  confidence  in  himself." 


394  SHELL-SHOCK:    NATURE  AND   CAUSES 


Bullet  wound  of  neck :  Late  sympathetic  nerve  effect. 


Case  285.     (Tubby,  January,  1915-) 

A  Belgian  was  wounded,  October  21,  1914,  at  Dixmude. 
The  bullet  wound  was  just  below  the  right  mastoid  process. 
He  was  admitted  to  the  London  General  Hospital,  October 
29.  He  said  that  the  bullet  had  passed  into  the  tonsil, 
lodging  there,  but  that  on  the  third  day,  while  vomiting,  he 
brought  up  the  tonsil  with  the  bullet  in  it.  There  was  in 
fact  a  large  ragged  wound  at  the  site  of  the  right  tonsil.  He 
could  swallow  fluids  only,  but  articulated  clearly.  There 
was  a  question  of  injury  to  the  following  nerves:  facial, 
glossopharyngeal,  vagus,  hypoglossal,  spinal  accessory,  and 
sympathetic.  None  of  these  nerves,  however,  appeared 
actually  to  have  been  injured.  The  difficulty  in  swallowing 
was  due  probably  to  the  faucial  wound,  and  it  is  hard  to  see 
how  the  pharynx  could  have  been  involved  on  account  of 
the  perfect  articulation.  November  3  the  right  sympathetic 
nerve  was  slightly  affected ;  the  right  pupil  was  smaller  than 
the  left  although  it  reacted  to  light.  November  12  the 
patient  left  the  hospital  and  nothing  further  is  known  of  his 
history.  Thus  there  was  a  late  effect  upon  the  sympathetic 
nerve  thirteen  days  after  the  wound. 

Re  peripheral  nerve  disorders,  see  remarks  under  Case 
252  (Tubby). 


SHELL-SHOCK:  NATURE  AND  CAUSES         395 


Fall  from  horse  under  shell  fire :  Crural  monoplegia, 
hysterical.     Reminiscence?  Autosuggestion? 


Case  286.     (Forsyth,  December,  191 5.) 

A  patient  of  Forsyth  had  been  exercising  a  high-spirited, 
horse.  Artillery  fire  close  by  made  the  horse  leap  sidewise, 
and  the  rider  fell,  his  back  striking  the  ground.  He  seemed 
to  be  curiously  shaken  out  of  proportion  to  the  gravity  of 
the  fall.     In  a  day  or  so,  he  lost  the  use  of  one  leg. 

He  recalled  a  rather  similar  incident:  He  had  taken  a  hand 
in  a  local  uprising  in  a  distant  quarter  of  the  world.  While 
he  was  escaping  up  a  mountain  track,  a  rifle-shot  from  the 
enemy  brought  down  his  horse,  which  rolled  over  and  threw 
him  violently  against  a  boulder,  where  the  small  of  the  back 
met  the  force  of  the  impact.  He  felt  intense  pain  and  lost 
consciousness.  Upon  recovery  he  found  he  was  paralyzed. 
At  the  end  of  several  days,  in  a  hiding-place  in  the  rocks,  he 
found  himself  still  unable  to  move  his  legs.  The  friend  who 
had  carried  him  to  the  hiding-place  refused  to  leave  him. 
He  thought  of  suicide,  but  then  discovered  that  he  could 
move:  at  first,  the  big  toes,  then  the  ankles,  then  the  knees, 
and  finally  the  hips.     He  was  finally  able  to  get  into  the  saddle. 

Moreover,  years  before,  he  had  heard  that  a  man  who 
broke  his  back  was  paralyzed  in  the  legs. 

Re  autosuggestion,  Babinski  remarks  that  suggestion  may 
work  in  hystero-organic  cases  not  precisely  as  in  hysterical 
cases.  Autosuggestion  may  here  replace  or  accompany  the 
ordinary  heterosuggestion.  Some  temporary  disturbance  — 
a  slight  pain,  a  trivial  injury,  or  a  mere  bruise — may  start  up 
a  complex  process  of  autosuggestion  in  which  it  may  be  diffi- 
cult to  unravel  the  part  played  by  the  patient's  own  reflexes, 
his  previous  experience  and  beliefs  (in  this  case,  the  remi- 
niscences of  a  similar  accident),  the  solicitude  of  his  friends, 
and  the  medical  examination  itself.  Babinski  believes  that 
hysterical  paraplegia  or  monoplegia  never  appears  automati- 
cally under  the  influence  of  emotion ;  never  appears  after  the 
manner  of  sweating,  diarrhea,  or  blushing. 


396  SHELL-SHOCK:    NATURE  AND   CAUSES 


Shell  explosion;   struck  in  cave-in:    Sjrmptoms  in 
right  leg  (antebellum  experience). 


Case  287      (Myers,  March,  1916.) 

A  private,  26  years  old,  had  11  months'  service  and  one 
month's  serv'ice  in  France.  He  arrived  at  a  base  hospital 
the  day  after  his  shock.  Concussion  had  caused  the  dug-out 
in  which  he  was  standing  to  collapse.  A  beam  struck  him 
on  the  left  side  of  the  face,  and  pinned  him  to  the  ground  on 
his  right  side.  A  piece  of  iron  fell  on  the  left  side  of  his  back, 
and  his  right  leg  was  pinned  by  a  cross  beam  on  the  back  of 
his  thigh.  He  was  dazed  by  the  shock;  was  released  and 
was  able  to  walk,  but  complained  of  a  pain  in  the  right  groin 
and  a  gi\-ing-way  of  the  right  knee.  The  medical  officer 
arrived  about  an  hour  later.  A  numbness,  or  state  of  no 
feeling,  in  the  right  thigh  appeared,  and  increased  to  the 
point  of  total  analgesia  to  the  level  of  the  upper  margin  of  the 
patella  save  for  a  narrow  strip  in  the  mid-Hne  on  the  posterior 
aspect  of  the  leg.  The  only  area  of  complete  anesthesia  and 
algesia  was  on  the  outside  of  the  lower  half  of  the  leg. 

According  to  the  patient,  it  seems  that  about  three  years 
before,  he  had  been  buried  four  feet  deep  in  a  brick  yard, 
beneath  a  heap  of  clay.  He  had  felt  it  most  in  the  right  leg, 
but  the  thigh  had  been  merely  stiff  and  sore,  and  not  numb. 
The  patient  admitted  that  the  present  accident  immediately 
reminded  him  of  his  pre\aous  experience.  There  were  no 
tremors  or  sensory  disorders  in  the  face,  arms,  chest,  back, 
or  abdomen.  There  was  diminished  sensibility  to  cotton 
wool  of  the  left  buttock  (across  which  a  plank  had  fallen), 
and  there  was  a  degree  of  hypalgesia  of  the  buttock.  The 
right  thigh  showed  a  degree  of  thermanalgesia  and  slight  loss 
of  vibratory  sense.  The  corneal  and  conjunctival  reflexes 
were  diminished,  and  the  knee-jerk  was  unobtainable  on  the 
right  side.  Three  days  later,  there  was  a  marked  improve- 
ment with  almost  complete  return  to  normal,  whereupon  the 
patient  was  sent  to  a  convalescent  camp. 


SHELL-SHOCK:    NATURE  AND   CAUSES  397 


Emotional  subject,  ALWAYS   WEAK   IN   LEGS; 
shell  explosion;  wound  of  back:  PARAPARESIS. 


Case  288.     (Dejerine,  February,  191 5.) 

A  Lieutenant,  25,  was  wounded  at  Arras  about  10  a.m. 
October  20,  1914,  just  as  he  was  leaning  on  another  officer's 
shoulder  looking  at  a  card  in  a  chateau  room.  A  shell  burst 
in  the  court  yard.  A  fragment  came  in  the  window,  struck 
him  in  the  back  and  pushed  him  forward,  whereupon  he  felt 
pain  in  the  back  and  a  severe  dyspnea,  due  to  the  gas  from 
the  shell.  He  lost  consciousness  several  times  and  the 
dyspnea  lasted  for  about  two  hours.  When  he  was  picked 
up  he  could  not  walk. 

He  was  carried  on  a  stretcher  to  the  ambulance  at  Avin- 
le-Compte.  During  the  fortnight  there,  he  was  also  several 
times  dyspneic.  Strength  left  his  legs  and  he  could  only  get 
about  on  crutches.  There  was  now  a  suppurating  wound  in 
the  interscapular  region  where  he  had  been  struck  by  the 
shell  fragment.  Evacuated  to  Paris,  he  was  operated  upon 
on  account  of  a  tremendous  abscess  in  the  back,  and  the 
shell  fragment  and  some  bits  of  cloth  were  removed.  The 
wound  healed;  but  vague  pains  in  the  left  thorax  remained, 
especially  when  the  man  walked. 

On  examination,  July  28,  1915,  he  would  in  the  stand- 
ing position  hold  his  legs  together  with  the  feet  resting  on 
their  external  borders,  especially  on  the  left  side.  The  toes 
were  in  plantar  flexion,  and  the  soles  were  arched  upward 
more  on  the  left  side  than  on  the  right.  In  walking,  the  legs 
were  always  held  in  extension,  the  feet  twisting  outward. 
If  an  attempt  was  made  to  walk  quickly,  the  man  walked 
more  and  more  upon  the  external  borders  of  his  feet,  in  such 
wise  that  the  plantar  surface  and  the  heel  turned  up  and 
became  visible  from  above.  He  would  get  tired  after  five 
minutes'  walking  even  if  he  spread  his  legs  out  for  a  broader 
base  of  action.  He  could  lift  his  legs  only  about  10  cm.  from 
the  bed,  but  could  flex  and  slowly  extend  his  lower  leg  on  the 
thigh.      He  could  not  adduct  or  abduct  the  feet.      Move- 


398  shell-shock:  nature  and  causes 

ments  of  extension  and  flexion  of  leg  on  thigh  were  jerky  and 
abruptly  terminated,  as  also  movements  of  thigh  on  hip. 
The  patient  could  not  sit,  and  when  leaning  forward  he  could 
not  straighten  up  against  resistance.  The  reflexes  were  nor- 
mal. There  was  no  sensory  disorder.  The  electric  reactions 
were  normal.  Pupils  normal.  There  was  slight  hyperten- 
sion of  the  spinal  fluid  and  a  slight  excess  of  albumin.  There 
were  no  lymphocytes. 

In  accordance  with  Dejerine's  idea  that  these  neuropaths 
always  have  antecedents  looking  in  the  same  direction,  it 
was  found  that  he  had  always  been  an  emotional  person, 
easily  affected,  sympathetic  with  other  people's  troubles, 
given  to  weeping.  As  Lieutenant,  he  had  not  had  the  cour- 
age to  harangue  his  soldiers.  He  had  often  during  his  life 
felt  his  legs  weaken  during  times  of  emotion  and  had  some- 
times been  unable  to  walk,  though  nothing  of  the  sort  had 
happened  during  the  campaign.  He  was  sure  he  could  get 
well,  and  wanted  two  months'  leave  in  order  to  get  back  to 
the  front.  There  were  no  hereditary  features  in  the  case. 
A  physician  had  told  him  that  he  had  had  meningitis.  This 
possibly  followed  whooping  cough.  He  had  had  orchitis 
after  mumps  at  i6.  He  had  not  had  children,  nor  had  there 
been  miscarriages  since  marriage  at  21. 


SHELL-SHOCK:    NATURE   AND   CAUSES  399 


Wound  near  heart ;  delayed  medical  care ;  fear  of 
having  been  shot  through  heart:  Paraparesis 
(antebellum  always  **  hit  in  the  legs.  ") 


Case  289.     (Dejerine,  February,  1915.) 

An  infantryman,  20,  was  sent  as  a  Colonel's  bicyclist 
about  I  p.m.  September  30,  1914,  with  a  message  to  one  of 
the  battalions.  He  was  exposed  on  the  way  to  shell  and 
rifle  fire,  and  was  wounded  by  a  bullet  which  entered  8  cm. 
below  and  internal  to  the  left  mammillary  line  and  came  out 
in  the  region  of  the  left  hypochondrium.  He  crawled  to 
some  village  houses  20  or  25  meters  away.  Another  cyclist 
came  to  transfer  the  order,  but  could  not  help  him.  A  friend 
came  to  his  aid  but  was  struck  by  a  bullet  10  meters  off  and 
remained  on  the  ground  for  an  hour  while  the  young  cyclist 
lay  behind  a  tree  on  the  roadside.  At  3  o'clock  it  was 
possible  to  take  him  to  a  house  around  which  shells  were 
raining.  Shortly  afterward  the  house  caught  fire.  The  man 
was  evacuated  6  kilometers  to  an  ambulance  in  the  night, 
and  that  night  six  of  his  wounded  comrades  died  in  the  same 
room.  The  man  had  lost  much  blood  and  began  to  think 
that  his  heart  had  been  hit.  He  choked,  had  violent  palpita- 
tions, and  Intense  thirst.  By  automobile  next  day  he  was 
taken  to  the  railway  station  at  Maison  and  was  there  for  a 
day  practically  without  food. 

That  evening,  36  hours  after  the  wound,  he  was  evacuated 
to  Juivisez  and  stayed  there  one  night  In  the  temporary  hos- 
pital. The  hemorrhage  had  now  practically  ceased.  When 
he  arrived  next  morning  at  Vincennes  he  could  hardly  move, 
was  unable  to  walk,  had  violent  palpitation,  precordial  pain, 
and  two  nervous  seizures,  with  outcries  and  weeping.  Sev- 
eral days  later  he  could  not  walk  at  all  or  raise  himself  in  bed. 
He  was  operated  on  May  29 ;  he  afterward  felt  the  same  leg 
weakness  and  was  still  unable  to  walk.  Early  in  December, 
when  observed  by  Dejerine,  he  was  able  to  stand  on  crutches 
with  legs  flexed,  toes  on  the  ground,  and  heels  up.  In  walk- 
ing he  would  scrape  the  ground  with  the  dorsum  of  the  foot. 


400  shell-shock:  nature  and  causes 

The  wound  was  now  healed.  Suppuration  had  been  intense 
and  the  scars  were  extensive.  Lying  down,  the  man  could 
move,  though  slowly,  his  lower  extremities  in  every  way, 
nor  was  there  any  diminution  in  the  strength  of  his  flexors 
and  extensors.  The  patient  in  making  movements  against 
resistance  w^ould  let  go  quickly  and  jerkily.  The  plantar 
reflexes  were  flexor  but  weak.  There  was  no  other  reflex 
disorder,  no  evidence  of  sensory  disorder,  nor  any  sign  of 
neuritis  or  arthritis.  Lumbar  puncture  gave  a  normal  fluid 
without  tension. 

There  were  no  hereditary  features  in  the  case.  The  man 
had  been  in  childhood  nervous  and  irascible,  rolling  on  the 
ground,  crying  and  weeping  when  crossed.  He  had  had 
three  attacks  of  appendicitis  —  one  at  15  years  and  two  at 
19  years.  After  each  attack  he  had  felt  weakness  in  the  legs. 
He  remembered,  too,  that  after  his  nervous  crises  on  being 
crossed,  he  had  always  felt  this  same  weakness. 

According  to  Dejerine,  these  paraplegic  neuropaths,  like 
functional  gastropaths,  cardiopaths,  and  victims  of  urinary 
disorder,  have  had  earlier  spells  of  the  same  kind,  though 
milder  than  the  attack  which  brings  them  to  medical  notice. 


SHELL-SHOCK:    NATURE   AND   CAUSES  4OI 


Wounds :  Tic  on  attempts  to  walk ;  tremors.  Re- 
covery except  for  frontalis  tic  (ANTEBELLUM 
HABIT  emphasized). 


Case  290.     (Westphal  and  Hubner,  April,  191 5.) 

A  substitute  officer  (mother  nervous;  always  slightly  ex- 
citable, easily  fatiguable;  had  had  a  habit  of  wrinkling  his 
forehead)  sustained  wounds  September  8,  19 14,  in  the  foot 
and  thigh.  The  wounds  healed  well,  but  in  the  hospital 
he  slept  badly  and  had  battle  dreams.  When  he  essayed  to 
walk,  he  had  contractions  of  face  muscles.  There  was  a 
lively  tic  involving  both  face  and  neck  muscles,  with  the 
head  pulled  to  one  side  and  backward.  This  grimacing 
was  but  slightly  infiuencible  by  the  will.  There  was  a 
marked  tremor  of  the  arms.  Gait  was  trippelnd.  There 
were  tremors  of  the  whole  body.  There  was  also  a  slight 
hemi-hyperesthesia.  The  tendon  reflexes  were  very  lively; 
vasomotor  disorders  (feelings  of  cold  and  perspiration). 

Seven  months  later  the  phenomena  had  all  disappeared 
except  for  slight  tic-like  frontalis  contractions. 

Re  heredity  and  soil,  Mairet  investigated  22  cases  of  Shell- 
shock,  and  found  a  hereditary  taint  in  eight,  and  an  ac- 
quired predisposition  In  nine.  He  found  hereditary  taint 
definitely  absent  in  seven,  and  acquired  soil  definitely  absent 
in  six;  whereas  the  rest  of  the  cases  were  doubtful.  He  found 
both  the  taint  and  the  soil  in  five  cases ;  two  cases  with  he- 
reditary taint  alone;  no  case  acquired,  non-hereditary. 

In  eight  cases  with  head  trauma,  Mairet  found  three  with 
hereditary  taint,  four  without  such;  against  one  with  an 
acquired  predisposition,  four  without  such,  others  doubtful. 

Re  cases  of  somatic  trauma  (not  afifecting  the  head) ,  among 
five  examined,  there  were  none  with  hereditary  taint,  three 
definitely  without  taint,  and  five  definitely  without  predis- 
position. According  to  Babinski,  neither  hereditary  taint 
nor  prepared  terrain  needs  be  found  in  hysterics. 

A  predisposition  is  not  thought  Important  by  Oppenheim, 
especially  as  so  many  normal  persons  are  predisposed. 


402  SHELL-SHOCK:    NATURE   AND   CAUSES 


War  strain  (fatigue,  emotion) :  Hysterical  hemi- 
plegia. Precisely  similar  hemiplegia  ANTEBEL- 
LUM. 


Case  291.     (RoussY  and  Lhermitte,  191 7.) 

A  sergeant  in  a  regiment  of  cuirassiers  was  observed  at 
Villejuif,  January  25,  1915.  He  had  lost  power  on  the  left 
side  as  a  result  of  fatigue  and  emotion,  November,  19 14.  He 
had  a  complete  paralysis  of  the  left  arm  and  a  paresis  of  the 
left  leg.  There  was  an  anesthesia  of  hysterical  type  in  the 
left  arm,  and  also  of  the  left  leg  as  far  as  the  middle  of  the 
thigh.  He  dragged  his  leg  in  walking  {demarche  en  draguant : 
the  toe  is  dragged  along  the  ground,  the  trunk  is  bent  for- 
ward, and  at  every  step  plunges  somewhat  toward  the  par- 
alyzed side.  The  patient  is  able  to  walk,  however,  by  means 
of  a  cane  or  crutches.  This  walk  is  characteristic  of  hys- 
terical hemiplegia.  According  to  Roussy  and  Lhermitte, 
the  number  of  cases  of  hysterical  hemiplegia  (better,  hemi- 
paresis)  is  not  large).  The  plantar  reflexes  on  both  sides 
were  those  of  flexion.  Upon  treatment  (not  specified),  at 
the  end  of  six  months  he  went  back  to  service  in  the  cavalry. 

The  point  of  note  in  this  case  is  that  this  patient  had  had  a 
precisely  similar  phenomenon  on  the  same  side,  which  lasted 
a  month,  at  the  age  of  sixteen  years  and  a  half.  It  is  note- 
worthy that  in  this  case  there  was  no  traumatism  and  only 
the  factors  of  fatigue  and  emotion  to  serve  as  an  occasion  for 
the  hemiplegia.  In  fact,  hysterical  hemiplegia  is  said  very 
rarely  to  follow  physical  trauma  to  an  extremity.  There  are, 
however,  some  cases  in  which  hemiparesis  follows  a  slight 
head  wound,  particularly  if  over  the  region  controlling  the 
paralyzed  limbs. 

During  the  six-months'  course  of  successful  treatment,  no 
atrophy  of  limbs  appeared,  and  there  was  never  any  in- 
equality of  the  reflexes. 


shell-shock:  nature  and  causes  403 


A  good  soldier  (son  of  a  tabetic  sometimes  hemi- 
plegic),  at  17  victim  of  hysterical  hemiplegia,  has 
AT  24  A  RECURRENCE  after  two  months'  field 
service.  "Functional  excommunication"  of  left 
arm  and  leg. 


Case  292.     (DuPREs  and  Rist,  November,  1914.) 

A  cuirassier,  24,  one  month  in  the  field,  began  to  feel  in 
September,  1914,  crawling  sensations  in  left  arm  and  leg; 
then  fingers,  later  hand  and  forearm,  and  finally  upper  arm 
began  to  work  awkwardly  and  feel  heavy,  and  there  was  a 
little  of  the  same  sort  of  thing  in  the  leg.  Hand  and  forearm 
were  by  the  middle  of  October  completely  paralyzed,  whereas 
the  arm  and  shoulder  were  only  paretic.  Anesthesia  at  this 
time  reached  the  elbow.  The  man  had  to  be  evacuated, 
after  two  months'  active  and  skilful  field  service,  in  one 
instance  (September  19)  carrying  out  a  clever  and  useful 
interception  of  hostile  telephone  messages. 

It  seems  that  at  the  age  of  17  also  the  man  had  had  a  left- 
sided  hemiplegia,  with  sensory  and  motor  symptoms,  last- 
ing two  months,  cured  by  electricity  applied  with  a  small 
electrode  in  his  village.  The  war  situation  was  therefore 
actually  a  recurrence  of  the  transient  hysterical  paraplegia. 

Moreover,  the  patient's  father,  52,  an  old  tabetic,  had  also 
several  times  shown  a  hemiplegia  (however  on  the  right 
side),  a  phenomenon  which  had  strongly  affected  his  son. 

It  was  curious  that  the  slight  residuals  of  movement  which 
the  cuirassier  could  perform  could  be  made  only  while  he  was 
looking  at  the  parts  he  was  requested  to  move,  and  were 
impossible  with  eyes  closed.  The  anesthesia  was  a  total  one 
when  observed  in  November,  1914,  coming  to  a  sharp  and 
circular  termination  at  the  shoulder  and  garter- wise  above 
the  knee  —  tuning  fork  Insensibility  in  the  same  areas.  The 
left  patellar  reflex  was  diminished  when  the  eyes  of  the 
patient  were  leveled  at  the  knee ;  but  a  surprise  test  brought 
the  knee-jerk  out  normally.  The  hand  and  fingers  were  a 
little  darker  in  color,  and  the  whole  left  arm  a  little  colder 


404  SHELL-SHOCK:    NATURE   AND   CAUSES 

than  the  right.  There  was  also  a  slight  amblyopia  on  the 
left  side. 

This  hysterical  paraplegia  proved  rather  resistant  to 
psychotherapy.  The  patient  seems  to  have  systematically 
eliminated  from  consciousness  and  from  action  the  entire 
function  of  the  left  arm  and  a  good  deal  of  the  left  leg.  Du- 
pres  and  Rist  speak  of  this  as  a  kind  of  functional  excom- 
munication of  the  parts. 

Re  relapses,  Wiltshire  remarks  that  the  frequency  of  re- 
lapses and  the  ways  in  which  they  are  produced  favor  the 
conception  that  the  original  cause  of  Shell-shock  must  be 
psychic.  Sir  George  Savage  remarks  that  cases  of  Shell- 
shock  should  not  return  to  the  service  under  a  period  of  six 
months  on  account  of  the  frequency  of  relapse.  Others  have 
recently  argued  that  such  cases  should  not  be  sent  back  to 
the  front  at  all.  Harris  notes  that  relapse  may  follow  so 
apparently  slight  a  factor  as  a  vivid  dream.  Remarks  con- 
cerning the  true  nature  of  relapses  are  made  by  Russell. 
Russell,  for  example,  disapproves  anesthetics  in  curing  such 
a  hysterical  phenomenon  as  deaf  mutism.  This  sort  of  treat- 
ment does  not  get  at  the  real  cause  of  the  condition,  so  that 
the  man  is  very  liable  to  relapse  with  the  same  symptoms. 
Ballet  and  de  Fursac  note  the  many  cases  of  relapse  after 
treatment  and  after  discharge.  Sometimes  the  relapses  were 
due  to  some  unfortunate  happening,  but  in  other  instances 
no  external  cause  could  be  made  out.  Fear  of  having  to 
return  to  the  front  is  a  factor  in  certain  cases,  so  that  the 
true  answer  to  the  relapse  question  may  not  come  until 
after  the  war. 

Roussy  and  Boisseau  insist  upon  the  value  of  rapid  cures 
(psychotherapy,  electricity,  cold  shower,  etc.),  in  diminishing 
the  number  of  relapses.  They  maintain  that  these  rapid  cures 
abolish  any  chance  for  the  man  to  brood  over  symptoms  and 
thus  to  exaggerate  and  fixate  them.  These  workers  send 
their  hospital  return  back  to  the  regiments  with  a  state- 
ment relative  to  diagnosis  and  the  request  that  he  be  imme- 
diately returned  to  hospital  if  neurotic  symptoms  appear. 


shell-shock:  nature  and  causes  405 


War    strain;     burial:     Deafmutism.     ANTEBEL- 
LUM speech  difficulty. 


Case  2^3.     (MacCurdy,  July,  1917-) 

A  private  20  (always  rather  tenderhearted,  disliking  to  see 
animals  killed ;  rather  self-conscious;  a  bit  seclusive ;" rather 
more  virtuous  than  his  companions";  shy  with  girls;  sore 
throat  a  year  or  more  before  the  war,  with  inability  to  sing 
or  talk;  always  a  lisper)  enlisted  in  May,  1916,  spent  five 
advantageous  months  in  training  and  became  increasingly 
sociable.  However,  on  going  to  the  front  October,  19 16,  he 
was  frightened  by  the  first  shell  fire  and  horrorstricken  by 
the  sight  of  wounds  and  death.  He  grew  accustomed  to  the 
horrors  and  five  months  later  was  sent  to  Armentieres,  where 
he  had  to  fight  for  three  days  without  sleep.  He  grew  very 
tired  and  began  to  hope  that  he  would  receive  wounds  that 
might  incapacitate  him  at  least  temporarily  for  service. 

He  was  suddenly  buried  by  a  shell,  did  not  lose  con- 
sciousness, but  on  being  dug  out  was  found  to  be  deaf  and 
dumb.  On  the  way  to  the  field  dressing  station  he  had  a  fear 
of  shells.  The  deafmutism  persisted  unchanged  for  a  month 
and  then  was  completely  and  permanently  cured  in  less  than 
five  minutes.  He  was  made  to  face  a  mirror  and  observe 
the  start  he  gave  when  hands  were  clapped  behind  him.  He 
was  assured  that  this  start  was  an  evidence  of  hearing;  that 
his  hearing  was  not  lost,  nor  was  his  speech.  He  had  no 
relapses  during  two  months. 

According  to  MacCurdy,  this  case  is  a  typical  one  of  war 
neurosis  of  the  type  of  a  simple  conversion  hysteria.  The 
man  never  suffered  from  anxiety  or  nightmares. 

Re  burial  cases,  Grasset  suggests  that  some  of  the  patients 
probably  think  that  they  have  actually  died ;  both  sensation 
and  motion  have  been  lost,  and  It  Is  naturally  these  that 
permit  a  man  to  believe  that  he  is  still  alive.  The  classical 
case  is  recalled,  of  the  almost  absolutely  anesthetic  boy  who, 
with  eyes  closed,  at  once  fell  asleep.  Foucault's  patient  also 
said  he  actually  thought  he  was  dead  after  an  explosion. 


406  SHELL-SHOCK:    NATURE   AND   CAUSES 


War  strain:  Shell-shock  and  psychotic  symptoms, 
with  determination  to  parts  injured  ANTEBELLUM. 


Case  294.     (Zanger,  July,  1915.) 

Several  years  before  the  war,  a  cavalry  officer  had  a  severe 
concussion  of  the  brain  after  a  fall  from  his  horse,  but  got  no 
manifest  symptoms  therefrom  except  a  mild  transient  deaf- 
ness. There  must  have  been  a  vestibular  nerve  injury,  how- 
ever, since  there  was  a  marked  bilateral  subexcitabiHty  of 
this  apparatus  later  determined. 

In  September,  1914,  as  the  result  of  strains  and  privation 
in  the  field,  he  got  vertigo  and  lachrymose  spells,  with  some 
obsessions  as  though  he  would  have  to  shoot  himself  in  the 
foot  or  spring  out  at  the  enemy  from  the  trench. 

In  hospital  at  Jena,  insomnia,  anxiety,  excessive  perspira- 
tion and  salivation,  feelings  of  the  death  of  various  parts  of 
the  body,  especially  the  forearms  and  hands,  associated  with 
hypesthesia  of  the  parts,  were  determined.  He  had  a  feel- 
ing of  vertigo  on  walking  and  was  very  sensitive  to  noise. 
He  now  developed  a  very  intense  and  very  variable  degree  of 
deafness  on  both  sides,  diagnosticated  as  nervous  deafness. 
The  caloric  test  demonstrated  vestibular  subexcitabiHty 
above  mentioned.  We  may  suppose  that  In  this  already 
injured  organism  fresh  disorder  had  set  in  on  a  psychogenic 
basis  in  the  same  region  that  had  been  injured  years  before. 


shell-shock:  nature  and  causes  407 


Mine  explosion; 

emotion  at  death  of  comrades: 

CTnconsciousness 

eight    days    with    hallucinatory 

delirium ;    later, 

dizziness.     History    of    previous 

trauma  to  head 

with  unconsciousness  and  dizzi- 

ness. 

Case  295.     (Lattes  and  Goria,  March,  1917.) 

Sent  at  end  of  May  to  the  front,  an  Italian  soldier  (Class 
1895,  laundry  man)  was  placed  in  an  advanced  post  where  he 
at  once  sustained  great  hardships. 

Father  drunkard,  mother  healthy,  sister  nervous.  Two 
brothers  healthy,  one  brother  died  of  tuberculosis.  Patient 
had  scrofula,  scarlet  fever,  and  bronchitis  (tendency  to  rave 
intensely  when  in  fever) .  At  four,  sustained  a  trauma  on  the 
head  (skull  depression),  dizziness,  loss  of  consciousness. 

June  7,  a  mine  exploded  in  his  vicinity,  smashing  several 
of  his  comrades.  He  did  not  himself  fall  to  the  ground,  but 
was  overwhelmed  by  a  violent  feeling  of  anguish.  After  a 
while,  he  lost  consciousness.  He  woke  up  at  Bologna,  June 
15,  as  after  a  long  sleep.  During  the  Interval  he  had  been 
in  a  state  of  intense  hallucinatory  delirium  day  and  night. 
Then  his  mind  began  gradually  to  clear,  first  with  amnesia 
of  the  shock  which  had  caused  the  trauma.  Then  he  recalled 
this  fact  too.  Dizziness,  however,  grew  in  Intensity  so  that 
he  fell  to  ground  many  times  during  the  day.  There  were 
intermittent  tremors  In  the  limbs. 

Under  observation,  August  7,  a  sturdy,  robust  man.  Some- 
what dull  in  demeanor.  Senses  intact.  Cranial  nerves 
negative.  Tendon  and  skin  reflexes  lively,  especially  on  the 
right.  Memory  Intact,  except  for  above-mentioned  oniric 
delirium  with  restlessness  and  shouting  at  night,  especially 
while  falling  asleep  and  waking  up.  Frequent  intense  dizzi- 
ness. 

The  condition  remained  unchanged  for  a  week.  Patient 
transferred  to  another  department,  for  acute  catarrhal 
bronchitis  with  fever. 


4o8  shell-shock:   nature  and  causes 


Sniper  stricken  blind  in  shooting  eye. 


Case  296.     (Eder,  March,  1916.) 

An  Austrahan,  19,  was  admitted  to  hospital  for  loss  of 
sight  in  the  right  eye.  There  had  been  a  right  ptosis  from 
childhood.     January  7  nothing  could  be  perceived  but  light. 

According  to  the  patient,  he  was  sniping  through  a  loop- 
hole, November  15,  when  a  bullet  knocked  a  piece  from  the 
stock  of  his  rifle.  He  continued  at  his  post.  There  were  five 
more  shots,  when  another  bullet  struck  the  sand  around  the 
loop-hole.  His  right  eye  began  to  water.  He  shut  the  loop- 
hole and  retired  for  an  hour.  His  eye  improved,  he  returned, 
opened  the  loop-hole,  braced  the  rifle,  and  found  he  could  not 
see  the  sights.  He  went  to  the  physician.  Vision  grew 
rapidly  worse,  and  in  a  few  hours  perception  of  light  failed. 
He  had  been  stricken  blind  in  the  shooting  eye  (the  seat  of  a 
congenital  deformity). 


Anticipation  of  warfare :  Hysterical  blindness. 


Case  297.     (Forsyth,  December,  191 5.) 

Anticipation  of  warfare  may  provoke  a  neurosis  as  in  a 
case  of  Forsyth's.     The  man  went  blind  training  in  England. 

It  seems  that  four  months  before,  while  mounting  sentry 
at  night,  marauding  gypsies  had  felled  him  by  a  blow  on  the 
head  from  behind.  He  had  returned  to  duty  after  a  day  or 
two  and  was  now  expecting  to  be  moved  to  France.  He 
said  that  while  sitting  with  a  friend,  he  began  to  feel  giddy, 
turned  a  somersault,  and  fell  unconscious;  and  that  on  coming 
to,  his  mind  was  clear  but  everything  was  dark.  For  ten 
days  he  had  been  blind,  although  once  he  could  see  his  parents, 
who  visited  him  in  hospital,  almost  clearly.  His  appearance 
under  examination  strongly  recalled  that  of  a  blind  man.  He 
was  induced  to  read  some  large  print,  then  smaller  print,  and 
finally  very  small  print.     He  then  lapsed  into  blindness. 

He  remembered  that  before  enlisting,  he  had  trained  in  a 
smithy,  and  heard  that  blacksmiths  often  went  blind  at  the 
forge. 


SHELL-SHOCK:    NATURE   AND   CAUSES  409 


Bareback    riding:     Spasmodic    neurosis     (similar 
ANTEBELLUM  episode). 


Case  298.     (Schuster,  December,  1914.) 

A  soldier,  32,  had  to  do  a  long  stretch  of  riding  bareback. 
As  a  result,  he  later  suffered  from  tonic  muscular  spasms 
whenever  he  had  to  exert  himself  seriously,  especially  when- 
ever he  had  to  move  his  legs  and  when  sudden  movements  or 
sudden  strong  contacts  were  made.  The  attack  appeared 
to  be  refiexly  dependent  on  the  pain.  The  case  is  regarded 
as  one  of  the  Wernicke  Crampusneurosen,  a  disease  some- 
what related  with  hysteria. 

A  condition  somewhat  like  the  one  developed  in  the  war 
had  occurred  in  this  man  at  the  age  of  seventeen  after  a 
drenching,  but  the  attack  was  at  that  time  much  milder.  He 
had,  however,  frequently  had  cramps  in  his  legs. 


ANTEBELLUM  spasm  of  hands,  functional. 


Case  299.     (Hewat,  March,  191 7.) 

A  boy,  19,  had  been  passed  as  fit  for  laboring  work  at  home. 
He  had  been  a  farm  boy  from  14.  Once  at  17  he  had  de- 
veloped whilst  working  amongst  turnips  in  wet  weather, 
pain  In  the  hands,  which  got  worse  and  was  followed  by  pains 
in  legs,  arm,  and  neck,  that  kept  him  in  bed  a  week,  and  from 
work  ten  days.  Even  on  returning  to  work,  his  hands  were 
swollen,  though  he  was  able  to  drive  a  horse.  The  fingers 
had  been  somewhat  firmly  flexed  on  the  palms  ever  since  this 
illness  at  17. 

He  was  sent  to  Netley  after  three  weeks  of  army  work,  as 
having  a  spasm  of  both  hands.  He  was  found  to  be  mentally 
below  par,  nervous,  apprehensive,  stuttering  in  speech  and  not 
readily  responsive,  with  defective  vasomotor  control,  though 
of  good  average  bodily  development  except  for  asymmetry 
of  chest. 


410  shell-shock:  nature  and  causes 

Both  hands  were  found  firmly  closed;  tips  of  fingers  ap- 
plied to  palms;  thumbs  freely  movable;  forearms  well  de- 
veloped, especially  the  flexors.  Counterforce  was  exerted 
upon  passive  extension  of  fingers.  There  was  no  sensory  or 
reflex  disorder,  and  while  the  patient  was  asleep,  it  was  found 
that  the  first  and  second  fingers  of  both  hands  could  be  fully 
extended.  Yet  there  was  a  definite  contracture  of  the 
palmar  fascia  which  prevented  full  extension  of  the  third  and 
fourth  fingers.  He  was  awakened  by  this  test  and  the  fingers 
became  firmly  flexed  at  once. 

The  man  was  treated  by  milk  isolation  behind  screens, 
without  permission  to  read,  smoke,  or  talk.  Twice  a  day  he 
was  encouraged  to  move  the  fingers  and  made  to  perform 
finger  exercises.  He  became  able  to  extend  the  fingers  over 
half  their  normal  excursion  in  three  days,  and  was  then  able  to 
abduct  and  adduct  the  fingers.  He  was  allowed  up  in  two 
weeks'  time,  with  full  diet  and  screens  removed.  The  con- 
tracture of  the  palmar  fascia  was  still  in  evidence,  but  the 
power  of  movement  in  the  hands  and  fingers  was  so  satisfac- 
tory that  he  could  be  sent  back  to  duty  in  three  weeks.  The 
interpretation  of  Fergus  Hewat  is  that  the  painful  condition 
of  the  hands  which  set  in  in  the  illness  at  the  age  of  17,  had 
caused  an  obsession  which  had  developed  into  a  functional 
spasm  of  the  hands. 


SHELL-SHOCK:    NATURE  AND   CAUSES  4II 


Quarrel:  Hysterical  HEMICHOREA,  DOUBLY 
REMINISCENT,  of  a  former  hysterical  chorea, 
itself  related  with  an  organic  chorea  of  the  patient's 
mother. 


Case  300.     (DuPUOY,  October,  191 5.) 

A  nineteen  year  old  soldier,  for  some  months  a  bit  dis- 
tressed and  irritable,  had  a  dispute  with  an  old  man  whose 
jug  he  unluckily  happened  to  smash.  The  old  man  said 
something  was  going  to  happen  to  him  for  that.  That  day, 
in  point  of  fact,  he  fell  and  sustained  an  injury  with  water 
on  the  right  knee.  He  was  upbraided  by  the  captain  and 
evacuated  to  the  ambulance.  The  fellow  thought  the  old 
man  with  the  broken  jug  had  interfered,  dreamed  of  the  old 
man's  threats,  and  felt  his  hand  on  his  shoulder. 

Next  day  hemichorea  developed  on  the  right  side,  a  partial 
and  rhythmic  chorea  with  jerky,  regular  contractions,  fifty 
to  sixty  per  minute,  affecting  synchronously  the  muscles  of  the 
leg,  arm,  face  and  tongue. 

Dupuoy  speaks  of  the  reason  for  the  hysterical  "  choice  " 
of  this  disease,  since  his  mother  had  had  a  probably  organic 
hemichorea,  also  on  the  right  side,  with  which  she  died  at 
thirty  years  in  a  stroke.  The  boy  was  at  that  time  thirteen 
years  old  and  had  had  a  rhythmic  chorea  six  weeks,  limited  to 
the  extensors  of  the  hand  on  the  forearm,  treated  in  hospital. 

This  new  hemichorea  was  quickly  and  completely  cured  by 
psychotherapy. 


412  SHELL-SHOCK:    NATURE   AND   CAUSES 


Hallucinations  and  delusions  in  a  soldier,  of  ante- 
bellum origin.    Treatment  by  explanation  of  causes. 


Case  301.     (Rows,  March,  1916.) 

A  private,  31,  —  a  case  of  Capt.  W.  Brown, — was  ad- 
mitted to  hospital  suffering  from  hallucinations  of  hearing 
and  delusions  of  supervision  by  his  family  and  friends;  he 
heard  his  relatives  telling  him  what  to  do  and  what  not  to  do. 
He  thought  they  belonged  to  a  secret  police  entrusted  with 
the  task  of  supervising  his  actions  and  seeing  that  he  did  not 
again  transgress  as  he  had  done.  An  inquiry  into  his  past 
revealed  the  following  facts: 

He  had  been  a  bank  clerk  before  the  war  and  once  because  of 
a  nervous  breakdown  as  a  result  of  drinking  and  smoking 
had  been  given  a  three  months'  vacation.  On  this  occasion 
he  went  with  a  prostitute  —  his  first  and  only  offence  In  sex 
matters.  He  later  thought  the  behavior  of  his  family  In- 
dicated that  they  knew  of  his  misdeed.  He  heard  the  voices 
of  members  of  his  family,  became  rapidly  worse  and  more 
depressed,  and  attempted  suicide. 

He  went  to  a  private  asylum.  Later,  he  emigrated  to 
Canada,  but  he  was  still  pursued  by  the  voices  and  he  returned 
to  England.  He  enlisted  at  the  outbreak  of  the  war  and 
went  to  France.  He  was  soon  invalided  and  sent  to  Mag- 
hull. 

The  cause  of  his  condition,  according  to  Rows,  was  his 
affair  with  the  prostitute  and  his  previous  drinking.  This 
was  explained  to  him  as  the  basis  of  his  strong  feeling  of 
self-reproach.  The  hallucinations  and  idea  of  suicide  had 
developed  therefrom.     Recovery  "  to  a  large  extent." 


shell-shock:  nature  and  causes  413 


A  poor  risk  (hereditary  and  acquired) ;  emotionality : 
Tremors  and  conviilsive  crises  with  lowering  of 
pulse. 


Case  302.     (Rogues  de  Fursac,  July,  1915.) 

A  man,  36  (boat  painter  to  30  and  thereafter  a  wine  seller; 
paternal  grandmother  insane,  father  alcoholic  and  suicide; 
gonorrhea,  20;  two  attacks  of  lead  colic,  25  to  30;  purulent 
pleurisy,  31;  phlegmon  of  mouth,  34;  also  a  chronic  alco- 
holic), at  the  time  of  examination  showed  arteriosclerosis 
and  slightly  hypertrophic  liver;  unequal  pupils,  slightly  con- 
tracted and  sluggish  to  light.  He  complained  of  frequent 
headaches,  possibly  due  to  a  combination  of  plumbism  and 
alcoholism.  He  was  not  in  any  respect  demented,  and  had 
an  excellent  memory.  He  had  always  been  emotional,  being 
unable  to  go  to  a  funeral  without  many  tears,  or  remain  in  a 
house  where  there  was  a  corpse  without  threatening  to  faint. 
He  was  always  overcome  if  he  saw  a  fight  going  on ;  and  even 
in  his  wine  shop  he  would  escape  when  there  was  a  fight  and 
get  a  neighbor  to  bring  the  police. 

He  was  mobilized  on  the  fifth  day,  sent  first  to  a  territorial 
regiment  and  then,  in  October,  put  into  the  reserve  of  an 
active  regiment  and  sent  to  the  front.  He  reached  the  first 
line  trenches  in  the  night,  greatly  affected  by  ruins  he  saw  on 
the  road.  He  slept  poorly  and  had  nightmares.  At  day- 
break he  woke  up  to  see  a  pile  of  corpses  near  by,  and  felt  an 
indescribable  terror  on  account  of  the  corpses  and  the  noise 
of  bullets,  machine  guns.,  and  shells.  By  superhuman  efforts 
—  according  to  the  man  —  he  mastered  his  emotions  and 
took  his  turn  at  the  observation  post.  Another  sleepless 
night.  Next  day  he  got  such  tremors  that  his  sergeant  sent 
him  to  the  hospital  where  he  was  at  first  thought  to  be  suffer- 
ing from  a  fever.  But  his  temperature  was  found  normal, 
and  he  was  sent  back  to  the  trenches. 

He  passed  another  night  without  sleep,  and  next  day  he 
could  not  hold  his  gun  for  trembling.  The  Captain  sent  him 
back  to  be  a  kitchen  man  in  the  rear,  and  here  he  remained 


414  shell-shock:  nature  and  causes 

six  weeks  —  restless,  trembling,  eating  very  little.  He  would 
have  anxious  spells.  In  the  morning,  as  he  was  carrying 
coffee  to  the  men  in  his  company,  on  seeing  a  pile  of  corpses, 
he  dropped  his  pot  and  ran  back  to  the  kitchen  declaring  that 
whoever  wanted  to  carry  coffee  might,  but  he  would  not  go 
back.  He  spilled  a  pot  of  soup  on  his  left  foot.  The  Captain 
had  him  evacuated,  saying:  "Go!  when  you  come  back,  I 
hope  the  war  will  be  over! " 

He  was  sent  back  to  a  hospital  near  Paris,  where  he  was  all 
right  for  a  few  days,  happy  as  a  prince.  The  burn  got  well, 
and  as  the  time  approached  when  he  would  probably  have  to 
go  back  to  the  front,  the  terror  returned.  He  had  visions  of 
corpses,  and  imagined  bullets  whistling,  machine  guns  pop- 
ping, and  shells  bursting.  He  wept,  lost  appetite,  hid  in 
corners,  made  three  suicidal  attempts  by  poisoning,  —  though 
the  sincerity  of  these  attempts  was  doubtful  (zinc  oxide  oint- 
ment; rose  laurel  leaves;  verdigris).  Sent  back  to  a  depot 
before  getting  leave,  he  had  crises  of  tremor  with  anxiety, 
and  was  then  sent  to  Val-de-Grace  on  the  mental  service,  and 
finally  to  Ville-Evrard.  He  unhesitatingly  confessed  his 
terror,  becoming  more  and  more  anxious  and  tremulous,  and 
almost  losing  his  pulse  while  describing  his  experiences.  He 
said  he  w^ould  commit  suicide  rather  than  return  to  the  front. 
He  stayed  at  the  Hospital,  working  in  the  garden  rather 
calmly,  but  when  it  was  a  question  of  leaving,  even  on  con- 
valescence, his  terror  and  anxiety  returned.  Every  time  he 
was  examined  there  was  an  emotional  explosion,  with  expres- 
sions of  anguish,  generalized  tremors  and  crises  of  clonic  con- 
vulsions with  respiratory  disturbance  even  of  threatening 
suffocation,  depression  of  pulse.  It  is  this  latter  which  is  the 
most  important  element  in  the  proof  that  such  a  case  is  not  a 
case  of  simulation. 

Re  war  cases,  Bennati  remarks  upon  the  great  number 
that  do  not  fall  into  known  categories.  There  is,  he  thinks, 
an  anaphylactic  group  in  which  the  trauma  acts  as  the 
secondary  toxic  agent;  and  there  is  another  group  in  which 
exhaustion  works  after  the  manner  suggested  by  Edinger: 
that  is,  by  a  physiological  overwork  of  certain  structures. 


SHELL-SHOCK:    NATURE  AND  CAUSES  415 


Martial  misfit,  dwelling  on  horrors  of  war  at  home ; 
exposure ;  shell  fire :  Mental  exhaustion  with  de- 
pression, emotionality,  tachycardia. 


Case  303.     (Bennati,  October,  1916.) 

An  Italian  corporal,  in  civil  life  a  writer  (mother  very 
nervous;  patient  himself  rickety,  unmarried;  relatives  well 
off),  was  in  front  line  trenches  for  some  fifty  days.  He  was 
repeatedly  excused  from  service  on  account  of  fatigue,  dis- 
tress, poor  appetite,  insomnia,  depression  and  even  confusion 
(aimless  shots  fired  off  in  the  night).  It  turned  out  that  he 
had  been  in  just  this  state  of  mind  when  he  left  home  and 
family  and  that  the  very  thought  of  war  had  seemed  dread- 
ful to  him.  He  did  not  at  all  enjoy  leaves  at  night,  as  he 
stumbled  and  fell  about  in  the  darkness  and  had  shells  burst 
near  by.  He  lived  immersed  in  mud.  He  reacted  unfavor- 
ably to  antityphoid  injection. 

The  very  day  he  went  on  winter  furlough  he  greatly  im- 
proved, but  then  suddenly  relapsed  into  depression,  emotion- 
ality, inattentiveness,  sluggishness  of  mind,  and  exhaustion. 
The  tendon  reflexes  were  lively,  the  abdominal  reflexes 
sluggish.  There  was  tachycardia  (120),  the  Mannkopf- 
Thomayer  tests  were  positive  at  76  and  80,  oculocardiac 
reflexes  84  and  vagotonic.     Stellwag  and  v.  Graefe  symptoms. 


4l6  SHELL-SHOCK:     NATURE   AND   CAUSES 


Hereditary  instability. 


Case  304.     (WoLFSOHN,  1918.) 

An  English  soldier,  23,  had  been  ten  months  on  active 
service  in  France,  when  he  was  buried  by  a  shell  December 
19,  191 5.  He  became  unconscious  and  later  suffered  from 
nervousness  and  stuttering,  depression,  insomnia,  frightful 
dreams,  and  tremor.  Improvement  was  such,  under  treat- 
ment, that  he  was  again  returned  to  the  front.  A  shell 
burst  near  him  once  more  and  again  he  grew  dazed,  trembled, 
had  lapses  of  memory  and  fell  into  a  state  of  general  nervous- 
ness.    He  improved  again  in  hospital. 

On  returning  to  the  front  in  a  few  days  he  saw  a  bomb 
burst  some  distance  away.  He  began  to  stammer  and  to 
wander  about  aimlessly.  Insomnia,  tremor  of  legs,  arms 
and  head,  fatiguability,  feeling  of  lassitude,  occipital  and 
vertical  headache,  fear  of  aircraft  and  crowds,  frightful 
dreams,  absences  and  aimless  wanderings  appeared.  There 
was  one  attack  of  deaf  mutism.  Whenever  the  patient  saw 
aircraft  he  ran.     He  was  easily  startled  by  noises. 

He  was  the  son  of  an  excitable,  alcoholic  father  and  of  a 
nervous  and  bad  tempered  mother.  A  sister  had  had  ner- 
vous prostration.  The  man  himself  had  always  been  more 
or  less  moody  and  a  nail-biter.  According  to  Wolfsohn,  74 
per  cent  of  the  war  neuroses  have  a  family  history  of  neurotic 
or  psychotic  stigmata,  including  insanity,  epilepsy,  alcohol- 
ism and  nervousness;  72  per  cent  show  previous  neuropathy. 

According  to  Wolfsohn,  wounded  soldiers  do  not  show  war 
neuroses  except  in  rare  instances.  In  the  wounded  soldiers 
studied  by  him  no  neuropathic  or  psychopathic  stigmata 
occurred  in  the  family  history  and  previous  neuropathic  tend- 
encies in  the  patients  themselves  were  found  in  about  10%. 

A  soldier  that  is  excessively  fatigued  or  has  been  under 
undue  mental  anxiety,  expecting  to  be  blown  to  pieces,  may 
go  into  psychoneurosis  more  easily  than  one  without  such 
emotional  strain. 


SHELL-SHOCK:    NATURE  AND   CAUSES 


417 


Genealogical  tree  of  a  shoemaker. 


Case  305.     (WoLFSOHN,    191 8.) 

An  English  private,  shoemaker,  37,  was  partially  buried  in 
a  shell  explosion  and  came  to,  stupid,  shaky,  weak  and  fear- 
ful of  the  dark.  Twice,  in  a  dazed  state,  he  attempted  to 
murder  companions  and  was  afterwards  amnestic.  He  had 
always  been  of  a  violent  temper  and  his  outbursts  had  been 
followed  by  petit  mal.  He  had  also  always  been  afraid  of 
the  dark.  One  of  his  children  had  fits;  three  were  hysteri- 
cal and  had  temper  fits.  The  man's  father  was  in  an  insane 
hospital.  Sundry  other  facts  are  show^n  in  the  genealogical 
tree  presented  herewith. 


Iviolenl;  bcmper 
prison  record 

I  insane- 
^  prosHVuta 
-^  itah&cile. 
-%  ITTibecile, 


Tniimbecile 
-■  tenvpev 


O 


-m  cJ-ooK. 


I  Violent  otiljursls 
(died  2s  result  of  one) 


Pedigree 

Hdte  "the  sH^mata  all  on. 
patern^  side. 

fTKe  ch"Sirt  reads  from  left 
to  ri^M.) 


a  St'CiVus  cLaiu:c 

I  crooX.i-etcl, 
prison  reiora. 


6 


sexual  manizc 


O 


insane  cnminal 
violent  temper 
se)tual  Tnaniac 

I    fits      , 

I  mental  dedea 

I  emotional 
enuresis 


violent 
outbTxrsVs 


^      o-utbursts 
YestramX 

I  nervous  break 
'down  follovvrs 
husi-'  oullmri'hs 


6 


I     PATIENT 
p«til-m.al 
I  violent  temper 


ms  oF 

tem-per 


Kysterical 
Ky^l  eric  al 


nervous 
I  clever  mvLsician. 
^^^  in  studied 


6 


4i8  shell-shock:  nature  and  causes 


Fall  from  horse  in  battle;  fear  of  being  crushed: 
Hysterical  crises.  Case  offered  as  showing  TRAU- 
MATIC HYSTERIA  in  a  young  physician  WITHOUT 
HEREDITARY  OR  ACQUIRED  PSYCHOPATHIC 
TENDENCY. 


Case  306.     (Donath,  1915.) 

A  physician  of  twenty  went  into  the  war  as  a  volunteer 
Hussar.  During  an  attack,  he  fell  from  his  horse  without 
losing  consciousness,  though  he  was  at  the  time  much  afraid 
of  being  crushed.  The  attack  ceased  and  he  returned  to 
the  lines  on  horseback. 

Immediately  there  developed  an  emotional  crisis,  and 
thereafter  he  broke  into  weeping  on  the  slightest  occasion. 
He  was  afraid  he  was  going  to  lose  his  reason;  that  some 
spiritual  power  was  going  to  suppress  his  ego  and  madden 
him.  He  wept  as  he  was  going  under  narcosis  to  be  operated 
upon  for  an  intercurrent  appendicitis.  He  became  so  sensi- 
tive to  noise  that  he  wanted  to  choke  the  offender.  One 
day  he  bit  himself  on  the  arm  in  his  excitement.  Sensory 
tests  could  not  be  executed  on  account  of  his  fear  of  the 
brush.     Reflexes  were  normal. 

It  took  four  hypnotic  seances  to  get  him  in  proper  rapport 
with  his  physician  for  psychotherapy. 

This  case  is  cited  by  Donath  as  one  in  which  traumatic 
hysteria  has  been  proved  to  exist  in  a  man  without  any  sign 
of  neuropathic  or  psychopathic  taint,  either  in  his  previous 
history  or  in  his  relatives. 


shell-shock:  nature  and  causes  419 


A  perfect  soldier  type.     Mine   explosion;  burial; 
superficial  wounds :  War  neurosis. 


Case  307.     (MacCurdy,  July,  191 7.) 

A  lieutenant,  29,  had  been  a  regular  soldier  for  eight  years 
before  the  war  and  was  made  a  non-commissioned  officer 
almost  at  once  after  enlisting.  He  went  out  as  a  sergeant 
with  the  original  expeditionary  force  and  got  through  the 
retreat  from  Mons  and  the  first  battle  of  Ypres  intact.  He 
enjoyed  the  fighting  hugely  and  even  got  indifferent  to  the 
burial  work.  The  death  of  chums  saddened  him,  but  he 
carried  on  and  soon  forgot  about  the  incidents.  He  might 
be  regarded  as  a  perfect  soldier. 

In  August,  19 1 5,  there  was  a  slight  touch  of  rheumatism. 
Two  or  three  months  later  the  Germans  exploded  a  mine 
immediately  in  front  of  the  trench  where  he  was.  He  went 
pale  for  the  first  time  in  his  life,  but  kept  his  men  "standing 
to."  Thereafter  he  began  to  think  for  the  first  time  about 
danger.  Mining  was  hereabouts  the  chief  form  of  attack, 
and  he  frequently  heard  Germans  digging  beneath  a  dug-out. 
He  slept  well  in  billets,  but  was  too  restless  for  sleep  on 
active  duty. 

He  got  more  and  more  on  edge  during  the  next  weeks.  Six 
weeks  after  the  mine  explosion  he  was  buried  in  a  dug-out. 
Though  he  did  not  lose  consciousness,  he  was  dazed  and  had 
to  lie  down  for  two  hours.  Nervousness,  chronic  headache 
and  insomnia,  even  in  billets,  followed.  His  imagination 
played  upon  the  blowing  out  of  dug-outs  and  the  bowling 
over  of  men  by  shells.  He  had  become  company  sergeant- 
major  and  the  responsibility  made  him  grow  worse  and  worse. 
At  times  he  tended  to  jump  when  the  shells  came,  but  was 
outwardly  perfectly  calm.  He  began  to  take  morphia, 
though  with  little  result.     He  had  suicidal  thoughts. 

After  two  months  of  these  symptoms  he  was  sent  to 
England.  He  began  to  sleep  fairly  well  and  three  months 
later  applied  for  light  duty ;  was  greatly  bored  by  the  company 
accountant  work  given  him;   got  a  commission  and  was  sent 


420  SHELL-SHOCK:     NATURE   AND   CAUSES 

back  to  the  front  nine  months  later,  January,  191 7.  He  got 
on  with  the  active  fighting  very  well,  sleeping  four  or  five 
hours  a  night.  In  April  he  was  sent  to  Arras.  He  had  had 
a  dream  that  he  was  going  to  be  bowled  over,  buried  and 
wounded  in  the  neck.  Sleep  got  poorer.  In  April  he  led  his 
men  in  an  advance  and  actually  was  bowled  over,  buried  and 
hit  in  the  neck  as  well  as  in  the  knee  and  the  hand,  though  all 
the  wounds  were  superficial.  He  was  carried  back,  dazed, 
to  hospital,  where  he  grew  fairly  comfortable  in  ten  days  and 
even  undertook  a  journey  down  to  the  base. 

He  arrived  in  collapse,  remained  in  camp  at  the  base  three 
weeks,  getting  steadily  worse.  Something,  he  could  not  tell 
what,  was  going  to  happen  and  kill  him.  He  could  not  con- 
centrate, even  to  read.  He  thought  of  suicide.  He  slept 
practically  not  at  all,  waking  from  a  doze  with  a  start,  feeling 
that  something  had  hit  him.  He  had  dreams  of  being  taken 
prisoner  and  on  waking  would  in  fancy  start  a  fight  to  escape 
from  imagined  imprisonment  back  to  the  British  lines.  After 
two  weeks  in  various  hospitals  he  spent  ten  days  in  a  hospital 
for  nervous  cases  and  grew  better.  Riding  on  trains  he  was 
terrorized  in  every  tunnel  lest  he  should  be  crushed. 

According  to  IMacCurdy,  an  anxiety  neurosis  would  have 
developed  had  not  his  superiors  sent  the  lieutenant  back  to 
hospital  after  the  final  burial  in  April.  As  this  perfect  soldier 
said:  '^  There  is  no  man  on  earth  who  can  stick  this  thing 
forever.''^ 


shell-shock:  nature  and  causes  421 


Shell-shock;  thrown  against  a  wall:  Tremors 
TREMOPHOBIA. 


Case  308.     (Meige,  February,  191 6.) 

Melge  has  studied  shell-shock  tremors,  especially  those 
occurring  without  external  wound. 

A  corporal  was  with  his  squad  on  the  Nouvron  Plateau, 
January  13,  191 5,  when  he  was  thrown  against  the  wall  by  a 
bursting  shell,  which  killed  or  wounded  several  comrades 
but  did  not  wound  the  corporal.  Whether  he  lost  conscious- 
ness is  unknown,  but  he  lay  on  the  ground  for  some  time, 
until  he  could  be  moved  through  a  communication  trench. 
After  the  explosion  he  began  to  tremble,  and  was  still  trem- 
bling on  his  trip  back.  Constantly  trembling,  he  lived  on  at 
the  front  for  a  fortnight,  but  without  eating;  and,  although 
he  had  been  a  good  rifleman,  he  had  lost  all  his  former  skill 
with  a  gun. 

There  was  a  delay  of  a  month  before  evacuation,  but  the 
trembling  did  not  cease,  and  he  was  passed  through  various 
units,  to  the  neurological  center  at  Villers-Cotterets,  where 
he  remained  for  two  months,  —  April  13  to  June  15,  191 5,  — 
with  a  diagnois  of  hysterical  chorea.  He  was  examined  by 
Guillain,  who  found,  besides  the  generalized  tremors,  lively 
knee-jerks  and  Achilles  jerks,  an  excessive  emotionality,  par- 
ticularly marked  when  the  guns  were  going  or  bombs  burst- 
ing.    Lumbar  puncture  yielded  a  perfectly  normal  fluid. 

June  19  the  corporal  went  to  the  Salpetriere  under  P. 
Marie.  July  14  he  was  evacuated  to  the  civil  hospital  of 
Arcueil,  where  he  remained  till  September  24,  when  he  was 
sent  home  to  convalesce,  from  October  26  to  December  15. 

He  returned  to  the  Salpetriere  December  15,  1915- 
Throughout  these  various  movements  from  hospital  to  hos- 
pital, his  status  was  unchanged.  At  the  time  of  report  about 
a  year  after  shell-shock,  he  was  still  constantly  and  uniformly 
trembling.  All  four  limbs  were  afifected,  perhaps  the  right 
arm  and  the  left  leg  more  markedly.     There  was  no  tremor 


422  SHELL-SHOCK:    NATUiRE   AND   CAUSES 

during  sleep,  but  there  was  a  tremor  when  the  patient  lay 
awake  in  dorsal  decubitus  just  as  when  he  was  sitting  or 
standing.  The  tremor  was  worse  in  the  evening  than  in  the 
morning,  and  the  patient  could  get  to  sleep  only  very  late. 
There  was  slight  tremor  of  the  head ;  the  eyelids  and  the  tongue 
showed  a  few  tremors,  which  were  not  synchronous  with 
those  of  the  limbs.  Nystagmus  was  absent.  To  diminish 
the  effect  of  the  trembling,  the  patient  held  his  forearms 
flexed  and  kept  his  elbows  close  to  his  body.  If  the  trem- 
bling of  the  legs  got  intense,  the  patient  would  rise  and  walk 
a  few  steps.  Any  movement,  such  as  carrying  a  spoon  or  a 
glass  to  the  mouth,  led  to  an  exaggeration  of  the  tremors; 
and  there  was  at  this  time  a  suggestion  of  the  intention 
tremor  of  multiple  sclerosis.  The  tremor  was  increased  when 
the  eyes  were  closed.  Any  sudden  noise  or  sharp  command, 
or  recalling  to  mind  of  trench  service,  would  bring  about 
extraordinary  motor  crises,  in  which  there  was  an  intense 
and  generalized  tremor,  so  the  patient  would  lose  his  balance. 
Any  attempt  at  eliciting  reflexes  would  produce  generalized 
violent  tremor.  Sensations  were  normal;  tendency  to  hy- 
peridrosis;  pulse  in  repose,  60,  rising  to  120  if  one  struck  the 
table  sharply. 

Meige  remarks  that  a  number  of  examples  of  tremors 
suggestive  of  Parkinson's  disease  were  observed  in  the  War 
of  1870.  Might  the  explosion  have  caused  properly  situated 
lesions  in  the  encephalon  of  such  a  nature  as  to  produce  a 
Parkinsonian  tremor?  The  tremors  were  stationary,  and 
if  due  to  some  lesion,  the  lesion  remains  now  exactly  what 
it  was  at  the  beginning.  There  was  no  digital  tremor  such 
as  is  characteristic  of  Parkinson's  disease.  Moreover,  the 
intention  tremor  of  such  a  patient,  rather  than  Parkinson's 
disease,  suggests  multiple  sclerosis,  of  which  latter  disease, 
however,  there  is  no  other  sign.  Nor  does  there  seem  any 
evidence  that  these  tremors  were  of  cerebellar,  paretic,  goi- 
trous, or  of  any  definite  toxic  origin.  On  the  whole,  Meige 
regards  it  as  a  neuropathic  manifestation  resembling  what  is 
found  in  traumatic  neurosis.  He  believes  that  there  is  not 
sufficient  evidence  that  it  is  the  consequence  of  any  struc- 
tural change  in  the  nervous  system. 


SHELL-SHOCK:    NATURE   AND   CAUSES  423 

Melge  remarks  that  the  analysis  of  any  case  of  tremor 
must  take  the  mental  state  into  account.  This  patient, 
perfectly  conscious  of  his  tremors  and  their  critical  exacerba- 
tions, was  much  chagrined  thereby.  He  suffered  mentally 
from  his  impotence,  especially  when  bystanders  would  in- 
tentionally bring  about  his  paroxysms.  He  looked  like  one 
shuddering  from  fear,  and  it  is  actually  probable  that  he  was 
afraid  of  his  own  tremors  and  shuddering.  He  was,  besides 
subject  to  tremor,  also  a  victim  of  tremophobia,  —  a  kind  of 
phobia  described  some  years  since  by  Meige,  somewhat  re- 
sembling ereutophobia,  or  fear  of  blushing,  described  by 
Pitres  and  Regis. 


424  shell-shock:  nature  and  causes 


Four  hours  in  a  freezing  bog:  Hysterical  glosso- 
labial  hemispasm  twelve  hours  after  rescue.  No 
sensory  disorder  of  face  or  tongue;  sensory  dis- 
order of  arm,  but  no  motor  disorder. 


Case  309.     (BiNSWANGER,  July,  191 5.) 

A  man,  27,  in  good  health,  called  on  the  second  day  of  the 
mobihzation,  got  into  the  line  two  weeks  from  mobilization, 
first  in  the  West,  and  then,  from  mid-September,  in  the  East. 
He  was  in  the  artillery  and  stood  shell  fire  in  a  big  battle 
very  well. 

However,  December  27,  1914,  while  engaged  in  transport 
service,  on  the  way  back  with  his  horse,  he  fell  into  a  bog 
and  gradually  sank  to  his  neck.  Attempts  to  get  the  man  and 
his  horse  out  failed.  All  that  saved  him  from  drowning  was 
the  freezing  of  the  bog  surface.  After  four  hours  he  was 
freed  by  his  comrades,  apparently  frozen  stiff,  but  with  con- 
sciousness completely  preserved.  On  the  next  day,  at  about 
five  o'clock,  —  twelve  hours  after  his  release  from  the  frozen 
bog,  —  he  had  a  seizure.  It  began  with  headache  on  the 
left  side  and  loss  of  consciousness  that  lasted  24  hours.  The 
right  leg  was  paralyzed  and  very  painful.  He  passed 
through  various  hospitals  and  finally  arrived  at  the  Jena 
Nerve  Hospital,  January  25,  191 5. 

He  was  a  tall,  powerful  man,  with  a  slow  regular  pulse, 
accelerated  heart  sounds,  lively  dermatographia,  increased 
muscular  excitability,  general  Increase  of  knee  and  Achilles 
reflexes  (left  greater  than  right),  slight  patellar  and  ankle 
clonus  present  on  the  left  side,  Babinski  reaction  absent, 
plantar  reflex  more  lively  on  the  left  than  on  the  right,  but 
abdominal  reflex  more  lively  right  than  left.  Head  painful 
to  percussion  in  the  left  temporal  region.  Touch  and  pain 
sense  segmentally  absent  in  both  right  extremities.  Arm 
movements  free;  tremors  absent.  Active  movements  almost 
impossible  in  the  right  leg;  on  passive  movement  marked 
pain.     Slight  muscular  tension  about  knee-,  hip-,  and  ankle- 


SHELL-SHOCK:    NATURE   AND   CAUSES  425 

joints.  The  patient  got  about  with  a  cane,  trailing  the  left 
leg.     Romberg  sign. 

The  right  angle  of  the  mouth  was  withdrawn  slightly 
upward  and  outward,  and  lagged  a  little  in  active  move- 
ments. The  protruded  tongue  deviated  completely  into  the 
right  angle  of  the  mouth  and  there  remained,  but  without 
tremor.  The  uvula  deviated  to  the  right,  and  the  right 
palate  was  held  higher  than  the  left.  Lively  palatal  reflex. 
Speech  intact.  The  patient's  chief  complaint  was  attacks 
of  coughing,  which  increased  his  headache  to  the  point  of  in- 
tolerability.  A  harmless  drug  caused  the  coughing  and 
headache  to  disappear.  The  patient  was  a  quiet,  willing 
man,  who  industriously  went  through  his  exercises,  and  on 
the  Kaiser's  birthday  was  already  walking  in  the  market- 
place. His  tongue  contractions  gradually  improved.  His 
body-weight  increased. 

In  the  course  of  two  months  the  glossolabial  and  palatal 
contractions  had  largely  disappeared.  The  walking  move- 
ments of  the  right  leg  had  improved,  although  there  was  still 
a  distinct  paresis,  and  a  stiffness  in  the  right  knee  and  ankle 
joints.  Climbing  stairs  was  impossible  on  account  of  diffi- 
culty at  the  hip.  March  30,  191 5,  the  sensory  improvement 
was  marked.  There  was  a  feeling  as  though  the  last  three 
fingers  of  the  hand  were  asleep;  walking  was  improved;  he 
could  walk  one  or  two  hours  a  day.  The  walk  was  still 
slightly  spastic- paretic,  May  28,  when  he  was  discharged. 

It  is  remarkable  that  the  hysterical  attack  had  such  a  long 
incubation  period  in  this  case:  twelve  hours  after  his  re- 
moval from  the  marsh.  There  were  doubtless  physical  factors 
of  refrigeration,  on  the  one  hand,  and  on  the  other,  psychic 
factors  of  fear  of  sinking  alive  in  the  marsh,  at  the  bottom  of 
the  phenomenon.  The  most  marked  feature,  of  course,  was 
the  glossolabial  hemispasm.  In  the  presence  of  this  hemi- 
spasm, it  is  remarkable  that  there  should  have  been  no 
anesthesia  or  analgesia  of  the  face,  cheek,  or  tongue;  and 
moreover  the  paresis  of  the  right  mouth  and  tongue  was  far 
less  marked  than  the  contracture.  It  is  also  striking  that 
the  right  upper  extremity,  although  it  had  sensory  disorder, 
failed  to  show  motor  disorder. 


426  shell-shock:  nature  and  causes 


Slight  bruise  by  horse :  Apparently  invincible  com- 
plaints of  pain.  Cure  by  single-handed  capture  of 
many  Russians. 


Case  310.     (Loewy,  April,  1915.) 

An  infantryman  was  standing  below  an  embankment  when 
a  horse  fell  upon  him,  bruising  him  slightly  on  the  left  hip. 
This  infantryman  later  continually  complained  of  pains  in 
the  opposite  hip  though  there  had  never  been  a  contusion 
there,  nor  anything  felt  there.  These  complaints  could  not 
be  influenced  by  exhortation,  by  diversion,  or  by  drugs.  If 
they  were  purposely  ignored,  the  patient  reacted  complain- 
ingly  and  in  a  way  to  suggest  delusions  of  persecution. 

Nevertheless,  this  querulous  man  soon  proved  an  effective 
soldier  in  a  storming  attack  in  which  the  whole  battalion 
distinguished  itself,  putting  himself  forward  particularly.  In 
fact,  by  himself  he  captured  a  whole  group  of  Russians! 

Thereupon  all  the  pains  in  the  hip  ceased,  nor  did  they 
recur  so  long  as  he  was  under  observation.  Morose  and 
complaining  before,  he  now  became  cheerful. 


SHELL-SHOCK:  NATURE  AND  CAUSES         427 


Kick  in  abdomen  by  horse:  General  spasticity; 
tremors ;  eye  symptoms  {e.g.  monocular  diplopia) ; 
convulsions.     Improvement. 


Case  311.     (Oppenheim,  July,  1915.) 

A  cuirassier  was  kicked  by  a  horse  on  left  side  of  abdomen, 
November  24,  and  lost  consciousness.  A  month  later,  in 
hospital,  hardness  and  tenderness  to  pressure  of  abdominal 
wall,  spastic  muscles  everywhere,  pseudospastic  tremor  of 
legs,  and  complaints  of  double  vision  were  noted.  He  also 
had  attacks  of  convulsions,  in  which  he  became  unconscious, 
twitchings  appeared,  but  the  tongue  was  not  bitten.  Urine 
was  often  involuntarily  passed  in  these  attacks,  but  he  was 
not  always  continent  outside  attacks,  as,  for  instance,  in 
coughing. 

On  admission  to  nerve  hospital:  Right-sided  monocular 
diplopia;  mild  ptosis;  ocular  movements  free.  Rapid  tremor 
on  shaking  hands.  Stood  with  straddling  legs  affected  by 
vibrating  tremor.  Knee-jerks  considerably  increased.  In 
the  dorsal  position  movements  of  the  left  leg  were  accom- 
panied by  marked  tremor.  He  even  could  not  go  to  sleep 
easily  on  account  of  twitching  of  the  left  leg. 

His  comrades  observed  that  he  had  convulsions  at  night, 
and  often  spoke  in  his  sleep.  Inoculation  against  typhoid 
fever  was  made  early  in  December.  Later,  permanent |rise 
of  temperature  to  37.8.  Several  attacks,  lasting  about  ten 
minutes,  came  under  observation  of  the  physician. 

In  January,  progressive  improvement  in  the  motor  sphere 
and  also  psychically.  The  urinary  disturbance  likewise  dis- 
appeared, but  the  spasms  persisted. 


428  SHELL-SHOCK:    NATURE   AND    CAUSES 


Windage  from  a  shell ;  fear ;  fail,  unconscious : 
Homonymous  hemianopsia  (organic?  functional?) 
with  blinking  and  vasomotor  excitability. 


Case  312.     (Steiner,  October,  1915.) 

A  volunteer,  19  (never  ill;  no  ner\'ous  disease  in  the 
family)  after  a  period  of  training  went  into  the  field  October 
3,  1914.  November  5  a  shell  struck  near  his  trench,  but 
failed  to  explode.  Up  to  that  time  everything  had  been 
quiet.  The  soldier  had  been  looking  out  of  the  loop-hole, 
surveying  the  landscape.  He  felt  a  great  fear,  felt  a  blow  in 
the  neck,  and  fell  down  unconscious.  How  long  he  was  un- 
conscious is  unknown.  Sometime  later  he  walked  back  with 
his  comrades. 

About  an  hour  later,  this  volunteer  —  who  was  a  very 
Intelligent  young  man,  possessing  some  knowledge  of  biology, 
including  the  nature  of  visual  fields  —  noticed  a  black  spot 
in  the  field  of  vision,  which  came  and  went,  but  after  a  few 
hours  remained  continually  without  disappearing.  Other- 
wise there  was  no  complaint  except  a  feeling  of  dizziness 
when  stooping. 

Upon  examination  there  could  be  found  no  disorder  of  the 
internal  organs.  Neurologlcally  there  was  blinking,  vaso- 
motor excitability,  slight  reddening  of  the  face,  and  derma- 
tographla.  An  expert  in  ophthalmology  confirmed  the  exis- 
tence of  a  homonymous  defect  In  the  fields  of  vision.  This 
defect  could  not  be  influenced  by  suggestion  or  by  any  other 
treatment,  nor  did  any  other  change  whatever  occur  In  the 
condition. 

Steiner  Inquires  whether  this  hemianopsia  Is  to  be  taken 
as  organic  or  functional.  The  air-pressure  of  the  shell  hiss- 
ing past  might  have  produced  a  concussion,  or  the  falling  un- 
conscious might  have  produced  a  commotio  cerebri  or  a  slight 
hemorrhage.  The  tic-like  blinking  and  vasomotor  excit- 
ability, however,  suggest  functionality. 


shell-shock:   nature  and  causes  429 


Shell-shock  PSORIASIS.     Post-traumatic  eczema. 


Case  313.     (Gaucher  and  Klein,  May,  1916.) 

A  soldier,  28,  came  to  the  Saint-Louis  skin  clinic.  May  15, 
1 91 6,  for  leg  lesions  three  months  old.  These  lesions  were 
cicatricial,  squamous,  irregular-contoured,  and  had  developed 
following  a  wound.     The  lesions  were  eczematous. 

On  the  trunk,  arms  and  elbow  were  lesions  of  psoriasis. 
These  lesions  had  appeared  after  shell-shock.  The  man 
had  been  bowled  over  June  16,  1915,  by  a  marmite.  The 
psoriatic  lesions  appeared  shortly  afterwards.  The  patient 
had  never  seen  anything  of  the  sort  before. 

In  this  case  the  trauma  provoked  eczema;  the  emotion, 
psoriasis.  Gaucher  and  Klein  say  that  they  have  been 
struck  by  the  recrudescence  of  psoriasis  since  the  outbreak  of 
the  war,  and  remark,  also,  that  there  has  been  a  relative 
increase  of  new  cases  since  July,  19 14. 

There  are  cases  of  psoriasis  following  nervous  shock, 
emotion  and  trauma.  Sometimes  the  psoriatic  lesion  de- 
velops upon  the  scar  of  a  wound.  In  the  above  case,  as  in 
the  case  of  a  woman  of  25,  a  refugee  from  the  Arras  bom- 
bardment, the  psoriasis  began  de  novo  and  slowly  developed 
immediately  after  the  catastrophe  of  the  Jena.  Five,  possi- 
bly six,  out  of  eight  cases  totaled,  appear,  unlike  the  case 
sketched  above,  to  have  developed  in  cases  either  tubercu- 
lous or  of  tuberculous  stock. 

Re  psoriasis,  Vignolo-Nutati  remarks  that  this  is  a  rela- 
tively frequent  skin  disease  amongst  Italian  soldiers.  He 
states  that  many  of  these  cases  are  due  to  nervous  shock. 
Some  are  related  to  wounds  appearing  near  the  scars.  In 
all  cases  an  emotional  disturbance  is  the  chief  cause.  Vig- 
nolo-Nutati had  86  cases  of  psoriasis  in  six  months,  52  of  the 
men  coming  from  the  front.  Eighteen  of  the  men  said  that 
they  had  not  previously  suffered  from  the  disease. 


430  shell-shock:  nature  and  causes 


A  sergeant  gets  the  CROIX  DE  GUERRE  and 
SHELL-SHOCK  together:  Transient  deafness; 
later  pseudohallucinatory  electric  bell  ringing,  rem- 
iniscent of  civilian  work;  stereotyped  movements, 
reminiscent  of  war  experience. 


Case  314.  (Laignel-Lavastine  and  Courbon,  May, 
1916.) 

A  sergeant,  24,  had  worked  about  Parisian  hotels  from  the 
age  of  thirteen  and  a  half.  He  won  the  croix  de  guerre  and 
was  evacuated  for  his  wounds  April  24,  1915. 

It  seems  that  he  carried  the  remains  of  his  company, 
which  had  been  decimated  the  night  before  by  a  mine  ex- 
plosion, on  to  the  enemy  trench,  getting  there  first  and  facing 
three  Germans,  whom  he  beat  down.  At  this  time,  gas 
shells  began  to  rain  about.  Making  a  number  of  violent 
expiratory  movements  to  get  rid  of  the  gas,  he  found  him- 
self unable  to  progress  on  account  of  the  fall  of  the  shells, 
and  sat  motionless  with  his  hands  before  his  face.  He  was 
cast  to  the  earth  by  an  explosion,  which  at  the  same  time 
blew  off  a  revolver  which  the  wounded  lieutenant  had  passed 
to  him.  He  sat  up,  and,  observing  that  the  soldiers  had 
gotten  the  trench,  went  back  to  the  lines,  where  he  told  his 
story. 

He  then  found  that  he  was  deaf,  and  wounded  in  the  left 
leg.  The  wounds  rapidly  healed,  but  sundry  other  symptoms 
developed.  He  had  a  peculiar  sensation  back  of  the  forehead. 
He  could  not  think,  read  or  write  and  was  very  weary.  He 
got  better  in  a  few  months,  but  disorders  kept  returning. 

His  deafness  had  left  him  in  about  a  fortnight,  but  when 
his  hearing  came  back  spontaneously,  there  were  peculiar 
sensations.  He  constantly  heard  an  electric  bell,  intense 
and  continuous,  like  that  of  a  French  cinema  advertising  its 
films.  The  sounds  seemed  to  begin  in  the  ear  and  to  run  out 
as  a  sort  of  whistling.  This  sensation  was  preceded  by 
buzzing  and  associated  with  noises  like  those  of  a  musical 
triangle  or  a  steam  whistle.     The  noise  kept  up  during  wak- 


[shell-shock:  nature  and  causes  431 

ing  hours,  but  was  often  forgotten  while  he  was  at  work.  In 
sleep  he  heard  nothing,  except  sometimes  battle  noises. 
August  20,  1915,  he  was  given  the  diagnosis:  labyrinthine 
shock  —  hearing  returned. 

About  ten  weeks  after  evacuation,  when  the  headaches 
and  thought  blocking  began  to  disappear,  a  generalized 
tremor,  especially  of  the  head,  set  in,  which  the  patient 
called  St.  Vitus'  dance.  Then  a  peculiar  gait  began,  which 
lasted  several  weeks  and  then  transiently  reappeared.  Every 
few  steps  his  legs  would  bend,  and  he  could  only  walk  for- 
ward in  the  attitude  of  a  man  who  is  concealing  his  height. 
After  resting  a  few  minutes  he  began  to  walk  regularly  again 
and  the  cycle  began  over  again.  He  had  to  walk  with  two 
canes.  If  he  felt  some  sudden  emotion,  or  sometimes  with- 
out any  obvious  reason,  he  would  stop  short  and  look  straight 
ahead,  with  body  bent,  and  arms  before  his  face.  This 
would  last  but  a  moment,  whereupon  he  would  walk  again 
normally. 

When  this  anomalous  walking  disappeared,  curious  face 
movements  and  gestures  began.  If  a  strange  person  arrived, 
the  forehead  and  eyebrows  would  contract,  the  eyelids  would 
stand  wide,  which  gave  him  an  expression  of  surprise  lasting 
a  few  seconds.  At  the  same  time  the  mouth  would  open  and 
remain  so  for  some  moments.  A  forced  expiration  would  be 
executed,  suggesting  a  fish  out  of  water.  He  would  then 
imperatively  strike  the  table  with  his  fist,  or  the  ground  with 
his  foot. 

Laignel-Lavastine  and  Courbon  explain  the  anomalous 
movements  as  stereotypies  due  to  secondary  automatism. 
They  are  not  convulsive,  are  not  preceded  by  emotion  or 
followed  by  a  sense  of  relief,  and  are  not  tics.  They  are 
gestures  and  postures  without  present  significance,  but 
adapted  to  certain  former  circumstances.  The  electric  bell 
effect  is  a  sort  of  pseudohallucinatlon,  differing  from  true 
hallucinations  in  little  except  the  absence  of  the  externaliz- 
ing feature.  The  stereotypical  movements  are  reproductions 
of  things  done  in  the  battle,  and  the  pseudohallucinations 
relate  to  the  former  hotel  work  of  the  soldier. 


432  shell-shock:  nature  and  causes 


Cinema  worker,  two  days  after  being  waked  up  by 
a  shell,  develops  a  nystagmiform  tremor  of  eyes  and 
tachycardia.  Graves' disease?  Tic  (''occupational 
virtuosity  ")  ? 


Case  315.     (TiNEL,  April,  191 5.) 

A  soldier  was  waked  up  with  a  start  Sept.  22,  1914,  by  a 
shell  burst.  The  man  was  not  wounded  or  shocked,  and 
merely  felt  a  good  deal  moved.  The  next  day  but  one  he 
felt  a  little  movement  of  his  eyes,  which  was  at  first  inter- 
mittent but  in  three  or  four  days  became  continuous  and 
troublesome.  These  movements  were  those  of  nystagmus, 
almost  transverse  and  very  rapid,  and  suggestive  rather  of  a 
vibratory  trembling  than  of  a  true  nystagmus  of  the  eye  or  of 
labyrinthine  disease.  When  the  patient  fixed  an  object,  the 
nystagmus  would  stop  for  a  few  seconds  and  then  immedi- 
ately reappear.  There  had  never  been  any  vertigo,  nausea, 
vomiting,  deafness,  ocular  disorder,  or  disorder  of  equili- 
bration. During  the  tests  for  nystagmus,  the  morbid 
nystagmus  would  stop  and  be  replaced  by  the  normal  nystag- 
mus which  was  obviously  slower  and  more  regular.  The 
condition  had  persisted  from  September,  1 914,  to  the  meeting 
of  the  Neurological  Society,  April  15,  191 5.  The  patient 
said  he  had  become  very  emotional  and  got  palpitations  on 
the  slightest  occasion,  such  as  a  fast  walk,  going  upstairs,  or 
hearing  a  loud  noise.  There  was  also  a  slight  vibratory 
trembling  of  the  fingers  and  a  permanent  tachycardia  (120- 
140  beats).  TInel  regards  the  case  as  one  of  neurosis,  due  to 
a  neuromuscular  hyperexcltablllty  comparable  in  some  ways 
with  that  found  In  Graves'  disease. 

Meige,  in  discussion,  called  attention  to  the  fact  that  not 
every  nystagmus  Is  of  organic  origin  and  that  there  is  a  rare 
form  of  tic  of  nystagmiform  nature.  The  victim  in  this  case 
was  an  employee  in  a  moving  picture  house,  and  very  pos- 
sibly his  occupation  had  permitted  him  to  utilize  what  Melge 
speaks  of  as  a  "occupational  virtuosity  "  of  the  eye  muscles. 


SHELL-SHOCK:    NATURE   AND   CAUSES  433 


Synesthesialgia:     FOOT     pain     on    rubbing    dry 
HANDS,  following  bullet  wound  of  leg. 


Case  316.     (Lortat-Jacob  and  Sezary,  November,  191 5.) 

A  foot  chasseur  was  wounded,  September  15,  1914,  low  in 
the  right  thigh,  a  bullet  entering  outside  the  biceps  tendon 
and  emerging  on  the  Inner  aspect  of  the  leg,  4  cm.  below  the 
knee  joint.  He  at  once  began  to  feel  pains  in  the  right  foot, 
which  grew  swollen  and  red.  The  leg  began  to  flex  upon  the 
thigh  and,  after  straightening  under  anesthesia,  was  placed 
in  plaster.  An  arteriovenous  aneurysm  developed  In  the 
popliteal  space;  operation,  October  22nd,  followed  Novem- 
ber I,  by  ligature.  The  pains  In  the  foot  grew  better  after 
this  operation;  but  as  soon  as  the  wound  was  cicatrized  they 
came  back  again  as  before. 

For  seven  months  the  foot  pains  remained  sharp  and  con- 
tinuous, such  that  the  man  could  not  leave  his  bed.  If  a 
bright  light  struck  his  eyes,  the  pains  grew  much  more 
marked,  especially  In  the  morning  on  awakening.  The  pa- 
tient found  that  when  his  hands  were  dry  he  could  not  use 
them  because  of  the  violent  pains  which  rubbing  them  would 
cause  In  the  right  foot.  Accordingly  he  kept  putting  his 
hands  to  his  mouth  to  moisten  them.  Finally  he  kept  a 
wet  rag  by  him  which  he  could  pass  from  one  hand  to  the 
other. 

The  pain  was  what  made  walking  difficult.  Foot  move- 
ments were  only  a  bit  less  ample  on  the  affected  side  than 
on  the  normal  side.  There  was  a  general  muscular  atrophy 
of  the  lower  extremity  (30.5  :  34  about  calf,  and  40  :  49 
about  thigh).  Right  knee-jerk  more  lively  than  left.  Right 
Achilles  jerk  absent.  Negligible  disorders  of  electrical  ex- 
citability in  the  territory  of  the  right  sciatic  nerve.  The 
skin  of  the  foot  was  a  little  thin  and  pale;  the  temperature 
was  low;  and  the  nails  had  transverse  striatlons.  The 
pains  grew  gradually  a  little  less  marked,  but  If  the  room 
temperature  was  Increased  or  lowered  or  if  the  foot  became 
cold,  the  pains  became  extreme.     Pressure  on  the  popliteal 


434  SHELL-SHOCK:    NATURE   AND   CAUSES 

space  produced  pain  on  the  external  border  of  the  foot ;  like- 
wise pressure  on  the  calf.  Lasegue's  sign  could  not  be  tested 
for  on  account  of  the  contracture  of  the  flexors  of  leg  on 
thigh.  Due  to  the  direct  action  of  the  bullet,  there  was  an 
objective  hyperesthesia  of  the  dorsum  and  sole  of  the  foot. 
The  toes  were  anesthetic.  A  cold  foot  bath  increased  the 
pains,  and  a  warm  foot  bath  diminished  them  (contrary  to 
experience  in  analgesias). 

This  was  a  case  of  synesthesialgia  in  the  right  foot, 
brought  about  by  rubbing  dry  hands,  exactly  as  if  there  were 
a  direct  contact  with  the  foot.  Milder  painful  reactions  were 
brought  about  by  bright  lights  and  loud  noises;  but  on  the 
whole,  these  other  effects  were  insignificant.  It  must  be 
remembered  that  the  man  was  wounded  and  plainly  had  also 
organic  nervous  disorder.  He  sometimes  complained  of 
radiations  of  the  pain  up  to  the  left  hypochondrium,  and 
sometimes  he  showed  the  classical  sensation  of  "esophageal 
globus  "  (lump  in  the  throat).  In  short,  there  was  in  him 
a  special  excitability  of  the  nervous  system  which  may  partly 
explain  the  synesthesialgia. 


shell-shock:   nature  and  causes  435 


Shell-shock;  burial:   Clonic  spasms;  later,  stupor 
with  amnesia. 


Case  317.     (Gaupp,  March,  1915.) 

A  reservist,  28  (laborer  in  civil  life,  of  a  nervous  family; 
even  before  mobilization  had  attacks  of  weakness  at  his 
work  or  in  the  company  of  others)  January  3  or  4,  191 5, 
fainted  in  the  trench  while  shells  were  striking  around  him. 
On  January  5  he  was  brought  to  hospital  in  deep  stupor.  He 
went  to  the  reserve  hospital  at  N.  by  hospital  train,  January 
8,  and  arrived  at  the  Tubingen  clinic  January  18. 

A  slip  of  paper  stated  that  after  burial  in  the  trench  he  had 
been  brought  from  the  field  unconscious.  Clonic  spasms  of 
the  upper  part  of  the  body  are  said  to  have  occurred.  At  the 
reserve  hospital  in  N.,  January  10,  he  was  still  unconscious, 
at  times  twitching  his  face  and  the  upper  part  of  his  body, 
and  once  at  night  excited  and  delirious. 

At  first  in  the  clinic  he  was  apathetic,  speaking  not  a  word, 
looking  vacantly  into  the  air  as  if  lost  in  a  dream.  He  went 
to  the  section  passively,  and  lay  passively  in  bed. 

In  the  examining  room,  he  stood  speechless  with  unemo- 
tional face,  sometimes  looking  up  to  the  celling,  slowly 
scratching  his  head,  failing  to  answer  questions,  although 
fixing  his  eyes  upon  the  physician.  He  could  not  be  com- 
municated with  in  writing,  playing  uncomprehendingly  with 
the  pencil  or  scratching  his  head  with  It.  He  would  start 
with  fright  at  a  sudden  noise  or  an  unexpected  touch.  Some- 
times he  would  heave  a  deep  sigh,  grasp  his  head  in  his 
hands,  or  lay  hold  of  his  hair  with  a  hopeless  expression  of 
face  and  shake  his  head  to  and  fro. 

Next  day,  January  19,  he  made  a  few  slow,  low  answers. 
He  was  found  to  be  entirely  disoriented  and  with  associations 
impeded,  although  he  could  get  out  his  name  and  residence 
with  difficulty.  Some  of  his  color  identifications  were  correct, 
such  as  red  and  green;  some  impossible,  as  yellow,  brown, 
violet.  A  comrade  who  was  called  in  and  could  speak  the 
Cologne  dialect,   was  talked  with  at    first  with  difficulty. 


436  shell-shock:  nature  and  causes 

later  more  easily.  Although  the  patient  was  visibly  freer, 
he  remained  without  apparent  emotion,  retaining  a  rigid  and 
dreamlike  expression  of  face.  It  was  hard  to  find  words, 
although  objects  were  named  correctly,  and  there  was  no 
paraphasia  or  agnosia.  Vision  and  hearing  were  normal; 
walking,  manual  movements,  eating  were  all  undisturbed 
though  slow.  The  patient  had  to  be  led  to  the  toilet.  It 
seemed  as  if  all  intellectual  life  was  at  rest,  and  that  in  the 
absence  of  impulses  from  without,  there  would  have  been 
complete  apathy.  It  was  made  out  that  the  patient  thought 
he  was  still  in  the  trenches. 

Next  day,  the  stupor  had  decreased  and  the  patient  spoke, 
getting  his  bearings  for  a  time.  There  was  a  complete 
amnesia  as  to  the  cause  and  duration  of  his  condition.  Dur- 
ing the  next  period,  up  to  the  beginning  of  February,  191 5, 
consciousness  cleared  and  the  apathy  was  replaced  with 
anxiety,  weariness,  and  a  dull  headache. 

During  February,  the  patient  gradually  returned  to  his 
senses,  and  remained  in  a  state  of  general  nervous  exhaus- 
tion. Amnesia  was  complete  for  at  least  two  weeks  of  his 
life  and  recollections  were  fragmentary  for  the  first  three 
days  of  his  stay  in  the  clinic.  He  worked  willingly  in  the 
garden  with  the  other  patients.  On  February  26,  the  patient 
was  cured  and  went  back  to  the  reserve  battalion  in  a  much 
strengthened  condition. 


SHELL-SHOCK:    NATURE   AND    CAUSES  437 


Battles  (including  liquid  fire) ;  eventually  shell- 
shock  :  Hallucinatory  delirium,  mutism,  asthenia  — 
after  a  few  days  puerilism  (history  of  convulsive 
crisis  in  adolescence)  with  regression  of  personality 
to  late  childhood. 


Case  318.  (Charon  and  Halberstadt,  November,  1916.) 
Puerilism  (Dupre)  appeared  in  a  soldier,  21  (uncle  and 
cousin  insane;  patient  had  difficulty  in  studies  at  fourteen 
and  nervous  spells  for  two  years,  with  loss  of  consciousness, 
fall  and  convulsions  probably  at  rare  inter\^als;  a  student  at 
eighteen)  after  he  had  taken  part  in  a  number  of  battles 
with  the  Chasseurs  Alpins.  He  was  exposed  once  to  liquid 
fire  July  21,  1916.  He  entered  the  military  psychiatric  cen- 
ter at  Amiens.  Mental  troubles  had  followed  the  bursting  of 
a  shell  near  him.  He  said  a  few  words,  such  as,  "Alsace; 
fire;  blood;  snow;  it  hurts."  These  phrases,  spoken  in  a 
loAv  tone,  with  an  anxious  appearance,  eyes  fixed,  suggested 
hallucination.  He  seemed  to  be  listening.  Aside  from  the 
isolated  words  above  mentioned  he  showed  complete  mutism. 
There  was  physical  weakness,  difficulty  in  walking  without 
support,  exaggeration  of  patellar  reflexes,  pains  in  the  head 
and  limbs.  After  several  days,  he  said,  "Milk;  bread." 
After  this  the  anxiety  and  the  slow  and  difficult  walking  dis- 
appeared, whereupon  the  puerilism  appeared. 

Now  the  soldier  began  to  run  instead  of  walking.  He 
galloped  and  gamboled  like  a  child  imitating  a  horse,  or  he 
would  sit  on  a  board  seeming  to  paddle.  He  would  skip 
along  the  halls.  The  puerilistic  phases  were  rather  brief  and 
for  the  most  part  he  lay  in  bed.  There  was  still  a  certain  as- 
thenia. He  made  little  paper  boats  in  bed,  keeping  them  in 
a  small  metal  box  along  with  bits  of  bread,  looking  glass  and 
the  like.  If  a  gesture  was  made  to  take  them  away,  he 
would  protest  and  press  the  box  to  his  breast,  looking  childish 
and  anxious,  and  if  the  box  were  taken  he  would  weep  hot 
tears.  Sometimes  he  would  stick  out  his  tongue  at  the 
attendants.     His  mother  came  to  see  him  and  after\vards  he 


43^  SHELL-SHOCK:    NATURE   AND   CAUSES 

would  say,  "Mamma  told  me  to  be  good,  to  eat  well,  to  get 
well  and  to  go  home."  He  would  use  childish  grammar,  — 
"Me  eat  much."  Asked  why  he  had  hollowed  out  a  small 
hole  in  the  wall  of  the  room,  he  answered,  "I  did  it  for  fun, 
but  I  will  not  do  it  any  more.  Mother  doesn't  want  me  to." 
The  patient  was  unwilling  to  answer  a  question  correctly; 
would  sometimes  answer  incorrectly  at  first  and  correctly 
afterward. 

It  appears  that  the  man  had  adopted  the  language,  occupa- 
tions and  attitude  of  a  child,  showing  a  regression  of  person- 
ality ten  to  twelve  years  backwards.  There  was  a  neurotic 
basis  in  the  convulsive  crises  of  adolescence.  On  the  basis 
of  this  predisposition  following  shock  there  appeared  an  at- 
tack of  confusion,  upon  which,  several  days  later,  super- 
vened ecmnesic  phenomena  of  hysterical  nature  assuming  all 
the  features  of  puerilism. 


shell-shock:  nature  and  causes  439 


Bomb-dropping  from  airplane;  unconsciousness: 
Battle  dreams.  Leaves  of  absence  failed  to  relieve. 
Episodes  of  dizziness  and  fugue. 


Case  319.     (Lattes  and  Goria,  March,  1917.) 

M.  Alessandro,  Class  '79,  baker  (father  a  drunkard; 
brother  an  idiot,  in  asylum),  had  typhus  in  youth,  and  as  a 
boy  had  periods  of  intense  "pavor  noctumus,"  but  no  con- 
vulsions. He  enjoyed  good  health  in  the  army  before  the 
following  event: 

On  July  13,  1915,  a  bomb,  dropped  by  an  airplane,  fell 
near  an  Italian  soldier,  killing  many  comrades,  and  throwing 
the  man  to  the  ground  unconscious.  He  awoke  several 
hours  later  at  a  hospital  in  a  stunned  condition.  During 
the  night,  under  the  influence  of  terrifying  dreams,  he  would 
leave  his  bed  to  look  for  enemies  who,  it  seemed  to  him,  were 
throwing  stones  and  firing.  He  managed  to  grasp  a  rifle  and 
fire  at  the  images  he  saw.  He  was  given  a  60  days'  leave  of 
absence  during  which  he  did  not  improve;  and  then  again 
90  days'  furlough,  which  he  spent  at  his  home,  where  terrify- 
ing dreams,  tremor  of  limbs  and  asthenia  continued. 

He  came  under  observation  February  10,  after  his  second 
leave.  Nutrition  fair.  Insomnia.  Constant  terrifying 
dreams.  Coated  tongue.  Tremor  of  hands,  head,  body, 
ceasing  during  voluntary  movements.  Episodically  he  had 
spells  of  dizziness  followed  by  absent-mindedness,  whereupon 
he  wandered  aimlessly  about,  of  a  sudden  becoming  aware  of 
being  in  a  place,  but  not  knowing  how  he  came  there. 

Special  senses  intact.  Several  points  of  cutaneous  hyper- 
esthesia, particularly  mammary  and  pseudo-ovarian  on  the 
left,  pressure  whereon  provoked  a  lively  emotional  reaction 
with  acceleration  of  pulse,  redness,  lacrimation.  Knee  re- 
flexes lively,  cutaneous  reflexes  normal,  except  the  plantar 
which  were  very  lively.  Restless,  hyperemotional,  he  wept 
for  insignificant  reasons  and  wanted  to  leave  hospital  for  fear 
of  dying  there.  He  was  discharged  unimproved  after  a  fort- 
night. 


440  SHELL-SHOCK:    NATURE  AND   CAUSES 


Nostalgic  temperament;  depression  on  entering 
service ;  rheumatism.  A  box  falls  from  an  airplane 
near  by:  Fear  and  tears;  later  depression,  nos- 
talgia, dreams,  hyperthyroidism. 


Case  320.     (Bennati,  October,  1916.) 

An  Italian  private  in  the  infantry  was  recalled  to  military 
service.  He  was  a  small  farmer,  and  being  disposed  to  home- 
sickness, grew  depressed  from  the  day  he  left  for  service. 
His  sleep  was  disturbed,  he  was  greatly  affected  by  the  wet 
and  damp  of  the  trenches,  and  was  in  a  state  of  continual 
fear.  Finally,  pains,  hypersensitiveness,  and  fever  de- 
veloped. 

As  an  enemy  airplane  passed  over  one  day,  a  box  fell  at 
the  man's  feet  and  threw  him  into  a  profound  fear  with 
tears.  He  was  conducted  to  a  tent  to  rest;  his  regiment 
was  shortly  sent  to  the  rear,  and  he  remained  on  active  ser- 
vice for  a  few  days  despite  the  fever  and  pains.  Finally  the 
swelling  of  his  leg  compelled  him  to  take  to  bed.  (Fatigue  in 
antebellum  life  had  always  shown  itself  in  aches  of  the  legs.) 
He  had  now  been  in  active  service  about  a  month  and  his 
homesickness  overcame  him.  He  was  in  a  state  of  deep 
physical  and  mental  depression.  It  was  not  his  own  troubles 
so  much  as  those  of  his  family  which  preoccupied  him.  His 
knees  hurt  him  so  that  he  had  to  weep;  or  if  Sardinia  was 
mentioned,  he  cried,  and  said,  "Oh,  how  I  love  Sardinia!" 
He  grew  fatigued  very  easily.  He  had  many  dreams  about 
Sardinia,  his  father,  and  the  war,  especially  dreaming  about 
being  wounded  in  the  legs  (question  of  being  stimulated  by 
the  joint  aches.)  The  reflexes  were  normal,  though  slight 
tremors  set  up  in  the  legs  after  testing.  The  thyroid  gland 
was  somewhat  swollen,  and  it  appears  that  the  patient  had 
noticed  this  five  days  before  entering  hospital.  The  patient 
was  rather  vagotonic;  pulse-rate  stood  at  56;  oculo-cardiac- 
refiex,  56-84;  Mannkopf  negative;  Thomayer  and  Erben 
marked  (56-88  and  88-60);  von  Graefe  marked;  Stellwag 
present. 


SHELL-SHOCK:    NATURE   AND   CAUSES  44 1 


A  shell  pitches  without  bursting :  Unconsciousness ; 
stupor ;  MAMA  MIA  ! ;  oniric  delirium ;  amnesia. 
Recovery  in  five  weeks. 


Case  321.     (Lattes  and  Goria,  March,  1917.) 

An  Italian  soldier  of  the  Class  of  '95,  a  mechanic  (mother 
cardiac;  as  a  boy,  pains  in  joints  and  heart;  since  boyhood, 
no  illness),  had  a  big  Austrian  shell  pitch  near  him,  July  23, 
1915.  The  shell  failed  to  explode  and  injured  no  one.  The 
patient,  however,  fell  to  the  ground,  unconscious,  and  re- 
mained In  the  camp  hospital  for  two  days,  quite  Immobile. 
This  event  followed  an  advance  by  his  company  under  very 
fatiguing  circumstances  without  sleep  for  a  period  of  four 
days. 

July  26,  the  patient  was  observed  In  profound  stupor,  non- 
reactive,  constantly  and  monotonously  repeating  the  phrase, 
Mama  miaf,  with  fixed  gaze  and  smiling  as  If  at  visions.  He 
swallowed  food.  The  pupils  reacted  poorly  to  light,  and  the 
cornea  and  nasal  mucosa  seemed  anesthetic.  The  tendon 
and  skin  reflexes  were  lively.  The  muscles  were  hypotonic; 
bradycardia,  56;   no  control  over  feces  or  urine. 

July  27-28,  restlessness  at  night,  gasping  movements,  and 
poses  of  terror. 

July  29,  he  called  for  his  mother,  who  had  been  dead  for 
several  years.     He  was  still  stuporous  and  insensible. 

From  August  I  to  10,  he  Improved  slowly  and  became 
able  to  carry  bread  to  his  mouth  after  It  had  been  put  In  his 
hands.  He  still  did  not  speak  and  made  signs  when  he 
wished  to  urinate  or  defecate.     Pulse  50-60. 

August  12,  the  patient  began  to  react  to  Intense  light  and 
to  pain  stimuli,  as  well  as  to  pressure.     He  ate  voraciously. 

August  15,  visual  stimuli  were  responded  to,  the  pulse  had 
risen  to  80,  the  skin  reflexes  were  no  less  lively.  There  be- 
gan to  be  terrifying  dreams  at  night,  with  motor  reactions. 

August  17,  the  patient  looked  about  more  alertly,  promptly 
seeing  bread  when  placed  In  the  center  of  the  field  of  vision 
and  saying  words  to  the  man  who  might  try  to  remove  the 


442  SHELL-SHOCK:    NATURE  AND  CAUSES 

bread.  He  did  not  yet  react  to  acoustic  stimuli,  nor  was 
there  any  other  change  up  to  August  21. 

August  22  a  notable  improvement  set  in.  The  hearing 
was  now  slightly  diminished,  questions  were  answered  after 
a  brief  refractory  period.  After  a  few  questions,  however, 
a  state  of  exhaustion  would  ensue,  which  would  disappear 
only  after  a  short  rest.  There  was  amnesia  for  the  entire 
period  following  the  day  of  his  departure  for  the  front.  May, 
191 5.  At  this  time,  instead  of  eating  voraciously,  he  showed 
anorexia.  The  skin  and  tendon  reflexes,  instead  of  being 
lively,  were  now  dull.  There  still  were  battle  dreams  of 
enemies  trying  to  kill  him. 

August  25,  there  was  an  area  of  hypesthesia  on  the  inner 
aspect  of  the  right  thigh,  but  otherwise  no  disorder  of  sensa- 
tion. The  pulse  stood  at  80  and  there  were  no  other  neu- 
rological phenomena. 

August  31,  the  patch  of  hypesthesia  of  the  thigh  and  the 
retrograde  amnesia  disappeared.  There  was  still  a  slight 
diminution  of  hearing.  The  accident  of  the  non-exploding 
bomb  could  now  be  recalled,  but  there  was  a  memory  gap  for 
all  facts  up  to  the  latter  part  of  August. 

September  2,  dreamless  sleep;  no  signs  of  abnormality 
except  a  slight  diminution  of  hearing.     Discharged,  well. 


SHELL-SHOCK:    NATURE  AND   CAUSES  443 


Jostled  canying  explosives;  no  explosion;  uncon- 
sciousness :  Deaf  mutism  and  foggy  vision.  Grad- 
ual recovery  from  these  symptoms.  Then,  on  ris- 
ing from  bed,  camptocormia. 


Case  322.     (Lattes  and  Goria,  March,  1917.) 

An  Italian  of  the  Class  of  1891  (convulsions  and  pains  in 
the  spine,  with  rigidity,  as  a  child;  typhoid  fever  at  18; 
brother  sickly,  neuropathic;  mother  subject  to  periodic  con- 
vulsions; father  alcoholic  and  nervous),  on  the  night  of 
November  26,  1915,  was  carrying  a  number  of  tubes  of  ex- 
plosives, A  comrade  stumbled  and  fell  over  the  soldier, 
who  fell  to  the  ground  unconscious.  None  of  the  glycerine 
tubes  exploded,  and  none  of  the  soldiers  round  about  were 
hurt. 

The  man  regained  consciousness  at  the  camp  hospital, 
but  remained  deaf  mute  and  also  impaired  as  to  vision.  It 
was  as  if  a  screen  of  fog  lay  between  him  and  objects  seen. 

During  fifteen  days  of  observation  at  the  camp  hospital, 
he  had  terrible  war  nightmares.  The  mutism,  the  visual 
disorder,  and  the  deafness  then  gradually  disappeared  with- 
out special  treatment. 

However,  when  the  patient  rose  from  bed,  it  was  found 
that  his  lumbar  vertebral  column  was  stiff.  He  walked  bent 
forward  and  was  unable  to  bend  or  straighten  the  back. 
There  was  a  hyperesthesia  along  the  vertebrae,  especially  on 
pressure.  X-ray  examination  showed  no  bone  lesion.  The 
larynx  and  cornea  were  sensitive,  and  the  plantar  reflexes 
were  absent.  The  abdominal  reflexes  were  present.  The 
pupils  reacted  to  light  and  accommodation.  There  were 
two  areas  of  analgesia  in  the  nipple  regions.  The  expression 
of  the  patient's  face  was  relaxed  and  drooping. 


444  SHELL-SHOCK:    NATURE  AND  CAUSES 


A  heavy  cannon  slides  and  grazes  a  man :  Uncon- 
sciousness; stupor;  amnesia  (anterograde  am- 
nesia persistent).  Complete  recovery  in  less  than 
seven  weeks. 


Case  323.     (Lattes  and  Goria,  March,  191 7.) 

An  Italian  soldier  of  the  Class  of  1895,  ^  peasant  (family 
healthy;  non-alcoholic;  good  scholar)  was,  July  19,  191 5, 
helping  drag  a  heavy  cannon  up  hill.  The  big  gun  slid,  hit 
several  men,  and  grazed  the  patient,  making  a  slight  abra- 
sion on  his  leg.  He  immediately  lost  consciousness,  and 
arrived  at  the  camp  hospital  in  a  stupor,  which  lasted  so 
long  that  catheterization  was  necessary. 

A  week  later  he  was  observed  in  hospital,  immobile  and 
non-reactive,  with  a  swollen  abdomen  and  fecal  impaction. 
The  pupils  were  widely  dilated  and  reacted  poorly  to  light. 
The  corneal  reflexes  were  absent,  and  the  nasal  mucosa  was 
anesthetic.  Pulse  50.  The  patient  failed  to  eat.  Next 
day  there  was  no  change  in  his  condition.  He  was  quiet 
throughout  the  night. 

On  the  morning  of  July  29,  a  number  of  answers  were 
obtained  to  questions  put  in  a  loud  voice,  though  he  was 
unaware  of  much  more  than  his  name,  being  ignorant  of  the 
name  of  his  country,  his  age,  his  division,  where  he  had  come 
-from,  what  had  happened  to  him,  or  where  he  was.  He  had 
now  begun  to  eat  spontaneously. 

During  the  following  days,  up  to  August  4,  the  amnesia 
gradually  dissolved  for  the  facts  before  the  trauma.  He 
remembered  having  been  greatly  frightened  at  the  time  of 
the  accident  but  could  not  remember  the  accident  itself,  and 
the  gap  for  subsequent  events  was  still  complete.  The 
pharyngeal  reflex  was  still  poor.  August  5,  he  began  to  re- 
member the  details  concerning  the  accident.  About  the 
middle  of  August  there  was  no  longer  any  diminution  of 
hearing  and  ideation  became  more  free  and  rapid. 

September  4,  he  was  discharged,  well. 


SHELL-SHOCK:    NATURE   AND   CAUSES  445 


Shell  explosions  SEEN :  Emotion ;   insomnia.     Ar- 
tillery HEARD  twelve  days  later:  "  finished  off." 


Case  324.     (Wiltshire,  June,  191 6.) 

A  lance-corporal,  36,  had  had  a  nervous  debility  four  or 
five  years  before  the  war,  caused  by  an  overstudy  of  music. 
He  had  not  stopped  work  at  that  time,  but  suffered  from  de- 
pression, anorexia,  and  insomnia,  lasting  for  some  weeks. 

The  lance-corporal  got  on  well  at  the  front  for  11  weeks, 
until  finally  eight  shells  pitched  near  him.  Although  he  was 
unhurt,  he  began  to  suffer  from  anorexia,  insomnia,  and  de- 
pression. While  in  billets  12  days  later,  some  English  artil- 
lery became  heavily  engaged,  whereupon  "The  noise  promptly 
finished*  me  off."  The  insomnia,  depression,  and  anorexia 
became  more  marked,  and  the  patient  could  not  sleep  unless 
heavily  drugged. 


446  SHELL-SHOCK:    NATURE  AND  CAUSES 


Shell-shock:  Emotion.  More  shells:  Insomnia; 
war  dreams.  Head  tremor  and  tic,  two  weeks 
after  initial  shock. 


Case  325.     (Wiltshire,  June,  1916.) 

The  psychic  trauma  is,  according  to  Wiltshire,  more  im- 
portant than  physical  trauma  in  the  following  case  of  a  ser- 
geant of  infantry,  28,  a  man  without  neuropathic  taint. 
This  man  had  been  nine  months  at  the  front  and  through 
Mons,  but  had  been  quite  well  until  three  weeks  before  com- 
ing to  hospital. 

"  Twenty- three  days  ago,  I  was  issuing  rations  when  they 
got  the  range  of  us  —  and  killed  the  other  chaps.  I  got 
blown  away  and  knocked  over.  I  saw  everything  —  fellows 
in  pieces.  Then  a  second  shell  came.  I  got  lifted  and 
knocked  about  ten  yards."  Then  he  began  to  shake  but 
carried  on. 

Two  days  later,  "Shells  dropped  on  the  dug-out  and  killed 
the  other  chaps.  I  have  not  slept  properly  since  this.  If  I 
go  to  sleep,  I  wake  up  seeing  people  killed,  shells  dropping, 
and  all  kinds  of  horrid  dreams  about  war."  One  or  two  of 
the  men  killed  had  been  pals. 

A  fortnight  after  the  first  incident,  while  in  a  base  hospital, 
head-shaking  began.  The  patient  would  jump  at  the  least 
sound.  There  were  spasmodic  tic  movements  with  the  ex- 
tension of  the  head,  protrusion  of  lower  jaw,  and  contraction 
of  occlpltofrontalls  muscle.  Sometimes  the  left  shoulder 
girdle  was  afifected  in  the  same  way.  There  was  a  slight  fine 
tremor  of  hands  and  eyelids  and  difficulty  in  keeping  the 
eyes  fixed  on  an  object. 


SHELL-SHOCK:    NATURE  AND  CAUSES  447 


Hyperthjrroidism,  hemiplegia,  irritative  symptoms 
after  exhaustion  (by  heat?). 


Case  326.     (Oppenheim,  February,  191 5.) 

A  man  (not  previously  nervous,  no  faulty  heredity,  heat- 
stroke August  21)  suddenly  fell  down  in  a  great  heat,  after  a 
fatiguing  march,  and  remained  unconscious  for  several  hours, 
waking  with  vertigo,  headache,  paralysis  of  left  side,  vomiting, 
and  twitching  of  the  face.  On  September  23,  admitted  to 
reserve  hospital.  Knee  phenomenon  increased.  Urinary 
retention;  catheter  used.  Speech  disturbance,  facial  twitch- 
ing. Vomiting  had  stopped  September  10.  Catheteriza- 
tion could  be  avoided  through  warm  sitz-baths.  October  30, 
on  sitting  up,  occipital  pain  and  vertigo.  November  15, 
urinary  symptoms  improved  Also  improvement  otherwise. 
December  i,  gait  vacillating  and  uncertain.  Headache. 
Admission  to  nerve  hospital,  December  3.  Here  complained 
of  twitchings  in  the  frontals  and  corrugators.  Wide  palpe- 
bral gaps.  Rare,  or  absent,  movements  of  lids.  The 
extended  hands  showed  active,  rapid  tremor.  Tendon  phe- 
nomena increased  in  the  arms  and  especially  in  the  legs. 
Abdominal  reflexes  increased.  Active  tremor  In  the  legs. 
Gluteal  tremor.  Very  pronounced  Graves'  symptoms.  Syn- 
dactylism very  pronounced  in  the  feet,  between  second  and 
third  toes.  Later  on,  improvement  under  half-baths,  etc. 
Worse  after  ten  days'  leave  of  absence,  especially  marked 
increase  of  tremor  (rest  tremor) ,  augmented  on  movement. 

Re  heat  stroke,  WoUenberg  has  called  attention  to  the 
effect  of  the  heat  of  the  summer  months  upon  German  sol- 
diers. Cases  of  heat  stroke  have  not  been  rare  In  the  German 
army.  About  half  the  cases  have  convulsions  or  epileptoid 
seizures,  as  well  as  tremors  and  nystagmus.  About  a  quarter 
of  the  cases  have  shown  confusion  and  delusions,  with  anxiety 
and  mania.  A  degree  of  mental  Impairment  has  followed  a 
number  of  these  heat  strokes,  together  with  sundry  signs  of 
organic  disorder,  such  as  reflex  changes,  pupillary  changes, 
and  difficulty  in  speech. 


448  shell-shock:   nature  and  causes 


Forced  marches;  skirmishes;  rheumatism:  Gener- 
alized TREMORS.     On  the  road  to  recovery  in  six 

months. 


Case  327.     (Binswanger,  July,  1915.) 

A  German  letter  carrier,  27,  entered  the  war  at  the  outset, 
made  forced  marches  in  great  heat,  was  in  a  number  of  skir- 
mishes and  in  the  capture  of  Xamur,  and  fell  ill  early  in 
September,  with  swollen  and  painful  right  foot  and  rheumatic 
pains  in  knees  and  shoulders.  He  was  put  on  garrison  duty; 
but  the  rheumatic  pains  in  the  joints  increased  toward  the  end 
of  September,  and  he  was  treated  in  hospital  for  rheumatism. 

He  became  able  to  walk  only  in  the  second  half  of  Decem- 
ber, marked  tremors  affecting  the  whole  body.  His  bodily 
condition  had  been  good.  He  slept  well,  and  while  at  rest  in 
bed  he  felt  entirely  well;  but  upon  every  attempt  to  get  up 
and  put  his  feet  down,  these  violent  trembling  motions  would 
always  reappear.  Treatment  by  hydro-  and  electrotherapy 
remained  entirely  unsuccessful.  February  8  he  was  trans- 
ferred to  a  nerA^e  hospital. 

He  had  been  in  the  postal  service  from  1903.  He  was  of 
normal  bodily  and  mental  development  and  had  had  no 
previous  illnesses.  His  military  service  had  been  executed 
from  1909  to  191 1.  He  had  always  been  a  passionate  smoker 
but  had  not  abused  alcohol.  His  mother  is  said  to  have  been 
for  some  time  paralyzed,  following  a  fright. 

Physically,  the  patient  was  a  slender  but  strongly-built 
and  fairly  well-nourished  soldier.  The  first  sound  at  the 
apex  of  the  heart  was  rough  and  impure,  and  the  heart  was 
somewhat  enlarged  to  the  left.  The  pulse  was  Irregular, 
106.  The  arteries  were  somewhat  stiff.  Neurologlcally, 
there  was  a  marked  dermatographia  of  comparatively  long 
duration.  The  periosteal  reflexes  were  increased;  the  deep 
reflexes  could  not  be  properly  examined.  The  whole  leg 
trembled  and  heaved  unsuccessfully  on  attempts  to  raise  it 
voluntarily.  After  even  a  slight  stroke  on  the  patellar 
tendon,  the  trembling  became  excessive  and  irregular,  and 


SHELL-SHOCK:    NATURE  AND  CAUSES  449 

the  leg  passed  into  a  heaving  spasm  which  would  outlast 
the  percussion  for  some  time.  The  patellar  clonus  could 
be  obtained  with  the  knee  extended.  The  shaking  move- 
ments were  somewhat  more  marked  on  the  right  than  on 
the  left  side.  Similar  phenomena  occurred  when  the  Achilles 
reflexes  were  being  examined.  The  triceps  reflexes  on  both 
sides  were  increased  but  there  was  no  tremor  or  spasm  of 
the  arms.  The  plantar  reflexes  were  very  lively,  and  fol- 
lowing these  reflexes  appeared  tremors  of  the  legs.  When 
the  spinous  processes  of  the  vertebral  column  were  per- 
cussed, a  general  shaking  spasm  appeared.  Tactile  sense 
was  everywhere  normal,  but  the  pain  sense  was  increased. 
Upon  slight  pin-pricks  in  the  skin  of  the  legs,  there  would 
occur  a  marked  shaking  spasm  of  the  leg,  passing  directly 
to  the  other  leg.  These  phenomena  were  more  marked  on 
the  right  side  than  on  the  left.  When  sitting  upon  a  chair 
with  back  supported,  a  slight  tremor  would  appear  when 
the  hands  were  raised  and  stretched  out,  more  markedly  on 
the  right  side  than  on  the  left.  Movements  of  the  arms  were 
normal.  However,  the  hand-grasps  were:  right,  105;  left, 
80.  In  dorsal  decubitus  the  movements  of  the  leg  were 
performed  comparatively  well  at  first,  but  after  a  few  repe- 
titions, the  shaking  spasm  would  occur  on  both  sides,  and 
the  movements  would  become  very  awkward.  The  heel- 
to-knee  test  would  then  fail.  If  the  patient  were  put  on  his 
feet,  he  would  immediately  fall  into  spasms,  first  in  the  right 
leg,  then  in  the  left.  The  trunk  would  now  be  involved, 
and  soon  the  arms,  whereupon  the  whole  body,  with  the 
exception  of  the  head,  would  be  seen  trembling  and  shaking, 
and  the  patient  would  fall  forward,  trying  to  get  support  by 
leaning  against  a  wall,  seizing  a  chair,  or  sinking  down  slowly. 
The  spasms  disappeared  at  once  in  dorsal  decubitus  and  in 
sitting  with  supported  back.  Outward  irritation  by  the 
acoustic,  optic  or  tactile  avenues  would  bring  out  spasms  in 
the  legs,  always  more  markedly  on  the  right  side  than  on  the 
left.  Psychic  irritations  would  cause  spasms.  The  muscles 
of  the  limbs  were  held  in  great  tension,  the  flexors  and  ex- 
tensors being  alternately  affected.  When  the  patient  was 
moving  along  a  wall  with  a  difficult,  swaying  gait,  his  efforts 


450  shell-shock:  nature  and  causes 

reminded  the  examiner  of  the  attempts  of  a  heavily  intoxicated 
man  to  walk.  Upon  attempts  to  create  passive  movements 
of  the  lower  limbs,  severe  shaking  and  trembling  movements 
set  in,  followed  by  a  general  spastic  tension  of  the  leg  muscu- 
lature such  that  it  could  not  be  further  flexed  or  extended. 

The  patient  was  put  in  the  psychiatric  section,  as  too 
seriously  ill  for  the  nerve  hospital.  He  improved  after  a 
few  days,  being  then  able  to  walk  without  much  support 
although  still  with  some  shaking  and  tremor.  If  his  atten- 
tion was  diverted,  passive  movement  of  the  leg  could  be 
carried  out  without  developing  spasm.  He  was  treated  in  a 
room  by  himself  with  removal  of  all  outward  irritation. 
His  legs  were  treated  for  an  hour,  three  times  daily,  by 
means  of  moist  packs.  On  account  of  complaints  of  insom- 
nia he  was  given  small  doses  of  hypnotics. 

The  main  thing  here,  according  to  Binswanger,  is  the 
psychotherapy.  The  patient  was  told  almost  daily  in  the 
course  of  conversation,  first,  that  the  illness  was  being 
cured;  secondly,  that  upon  recovery  he  would  be  employed 
in  the  future  only  on  the  postal  service.  He  was  told  that 
he  would  have  to  avoid  marked  physical  exertion,  of  course, 
but  that  he  still  would  be  fit  for  office  work  and  could  serve 
the  fatherland  in  this  way.  Still  he  could  not  be  trans- 
ferred back  to  the  hospital,  he  was  told,  unless  he  became 
entirely  well,  so  that  he  could  move  with  perfect  freedom. 

February  23  the  patient  was  performing  daily  exercises  in 
walking  and  standing;  the  spasm  became  very  slight  on 
standing,  and  often  would  entirely  cease,  but  it  remained 
still  plainly  present  in  the  legs;  the  trunk  and  arms  were 
free.  External  irritations  were  now  less  prone  to  excite 
spasm.  Sleep  became  quiet  and  dreamless.  He  was  trans- 
ferred to  the  nerve  hospital,  able  to  move  about  freely  in 
house  and  garden  and  only  tremulous  after  long  walks  and 
considerable  bodily  and  mental  fatigue.  He  was  given  a 
week's  furlough  home.  He  wished  very  much  to  get  into 
the  postal  service;  at  the  time  of  the  report  he  had  not 
attained  this  goal.  He  had  renewed  attacks  of  trembling 
upon  exertion,  and  was  transferred  at  the  end  of  June  to  a 
convalescent  home. 


SHELL-SHOCK:    NATURE  AND   CAUSES  45 1 


Shell-shock ;  emotion :  Hyperkinesis,  fear,  dreams. 


Case  328.     (MoTT,  January,  191 6.) 

A  private,  21,  was  with  30  men  carrying  sandbags  in  the 
daylight,  under  shell  fire.  He  was  thrown  into  a  deep  hole 
by  an  explosion,  climbed  out,  and  saw  all  his  mates  dead. 

He  was  admitted  to  the  Fourth  London  General  Hospital, 
June  20,  1915,  having  been  at  Boulogne  for  a  fortnight.  He 
was  lying  In  bed  on  his  back,  making  continuous  jerky  lateral 
movements  of  head,  and  movements  of  arms,  especially  of 
the  left  arm.  He  was  groaning  slightly,  now  and  then  raising 
his  eyelids  with  a  staring  expression  of  bewilderment  and 
terror.  He  was  able  to  mutter  answers  to  questions.  He 
would  occasionally  raise  his  right  hand  to  his  forehead.  If  he 
was  observed,  these  movements  became  exaggerated.  They 
ceased  in  sleep.  He  muttered  even  when  unobserved.  He  con- 
tinually said,  "  You  won't  let  me  back."  Asked  as  to  dreams, 
he  replied,  "Guns."  Voluntary  movements  were  made,  which 
prevented  obtaining  reflexes.  When  his  pupils  were  to  be 
examined  by  a  man  in  uniform,  he  showed  a  marked  fades 
of  terror;  his  pupils  were  dilated;  the  eyes  opened  wide,  the 
brows  were  furrowed,  and  there  was  an  anxious  scowl.  The 
flash  of  an  electric  light  produced  the  same  effect. 

June  24  the  patient  was  much  better.  He  said  the  ex- 
plosion which  had  killed  his  friends  after  he  had  been  only  a 
few  weeks  at  the  front,  was  the  first  serious  event  in  his 
service.  He  kept  seeing  it  again,  with  bright  lights  and 
bursting  shells.  Sometimes  he  would  hear  the  men  shouting. 
In  dreams  he  both  saw  and  heard  shells  and  men.  There 
was  pain  in  the  back  and  right  side  of  the  head. 

June  26  he  was  improved  but  still  had  pain  in  the  back  of 
the  head,  especially  when  trying  to  remember,  and  a  slight 
tremor  of  the  hands.  He  had  been  given  hot  baths  at 
Boulogne  on  account  of  being  very  cold  and  shivering.  He 
had  always  felt  sick  at  the  sight  of  blood.  He  was  boarded 
for  Home  Service  six  months  after  admission. 


452  SHELL-SHOCK:    NATURE   AND   CAUSES 


Shell  fire  and  barbed-wire  work :  Tremors,  anesthe- 
sias, temperature  and  pain  hallucinations. 


Case  329.     (Myers,  March,  1916.) 

A  corporal,  39,  had  been  working  under  shell  fire  at 
barbed-wire  entanglements.  The  man  was  big  and  robust, 
but  much  depressed,  complaining  of  noises  in  the  head, 
pricking  pains,  unsteady  legs,  fatigue,  irritability,  loss  of 
confidence.  He  showed  tremors  of  arms  and  legs  on  move- 
ment, and  stood  unsteadily  with  eyes  closed.  He  said:  " My 
legs  have  been  very  unsteady,  especially  when  some  one  is 
looking  at  me.    They  must  have  thought  me  drunk  at  times." 

The  head  and  tongue  were  tremulous,  the  knee-jerks 
exaggerated,  the  soles  insensitive  to  touch  and  pain;  but 
sensibility  to  deep  pressure  was  retained.  There  was  a 
gradual  return  of  right  answers  on  further  trials,  aided  by 
comparison  with  effects  of  stimuli  applied  to  the  dorsum  of 
the  foot.  Though  he  gave  correct  replies  on  heat  and  cold 
tests  over  the  arms,  he  gave  wrong  answers  over  the  dorsum 
of  the  feet,  less  often  over  legs,  sometimes  over  thighs. 

Later  during  examination,  the  feet  became  tremulous. 
He  felt  a  "silly  childish  fear,"  and  his  hands  began  to  feel  cold 
and  clammy;  whereupon  he  began  to  reply  hot  or  cold  when 
the  tubes  were  not  applied  at  all  (temperature  hallucina- 
tions). There  were  apparently  pain  hallucinations  in  the 
soles  and  errors  in  response  to  the  compasses. 

Re  the  temperature  hallucinations  noted  by  Myers,  these 
are  to  be  distinguished  from  true  vasomotor  disorders. 
Babinski  believes  that  he  has  definitely  established  that, 
though  hysteria  may  cause  a  slight  thermo-asymmetry,  yet 
never  a  definite  vasomotor  or  thermic  disorder. 

Re  hysterical  pains,  the  most  frequent  are  probably  those 
of  hysterical  pseudo  sciatica,  in  which  true  signs  of  sciatica 
are  absent,  namely,   (i)  loss  of  Achilles  jerk,   (2)  scoliosis, 

(3)  Lasegue's  sign  (pain  on  thigh  flexion  with  leg  extension), 

(4)  Neri's    sign    (with    trunk   bent   forward,    affected   knee 
flexed),  and   (5)  Bonnet's  sign  (pain  on  thigh  adduction). 


SHELL-SHOCK:    NATURE  AND  CAUSES  453 


Shell-shock:  Emotional  crises;  twice  recurrent 
mutism ;  amnesia.  A  comrade  in  the  same  explo- 
sion gets  off  with  transient  phenomena. 


Case  330.     (Mairet,  Pieron  and  Bouzansky,  June,  191 5.) 

December  15,  sitting  back  of  a  wall  were  three  minor  officers 
and  an  homme  de  liaison,  when  a  105  shell  punctured  the  wall 
and  burst,  killing  one  and  wounding  another  severely.  One 
of  these,  a  sous-lieutenant,  lost  consciousness  for  a  quarter  of 
an  hour  and  had  some  severe  headaches  for  a  few  days,  but 
nothing  more.  The  other,  the  homme  de  liaison,  was  found 
standing,  bewildered,  looking  at  the  dead.  When  his  name 
was  called,  he  jumped  and  started  off,  weeping  and  crying 
out. 

When  caught,  he  was  still  somewhat  clear,  recognized  his 
superior  officer,  answered  yes  and  no,  but  kept  asking, 
"Where  is  the  other?  "  Next  day  he  kept  weeping  and  said 
not  a  word. 

He  was  evacuated  through  a  series  of  hospitals  and  was 
sent  to  convalesce  with  his  sister  at  Montpellier,  having  now 
got  back  his  speech.  He  had  a  seizure  of  fear  in  the  street 
and  was  picked  up  by  the  police  and  was  carried  to  a  general 
hospital  January  21.  Here  he  could  not  speak,  could  hardly 
write,  being  unable  to  find  his  words.  He  walked  slowly, 
bent  over,  eyes  abnormally  wide  open,  with  a  look  of  terror. 
The  lighting  of  a  match  made  him  start  off  weeping.  The 
symptom  picture  included  tinnitus,  vertigo,  deafness,  some 
reduction  of  the  visual  field  (especially  on  the  left  side), 
hypesthesia  and  hypalgesia  on  the  left  side,  hyperalgesia  on 
the  right,  painful  points  (epigastric,  inguinal,  supra  and  infra 
mammary  left),  reflex,  muscular  and  tendon,  hyperexcita- 
bility  on  right  side,  jactitation,  impairment  of  recollective 
memory,  complete  memory  gap  for  the  accident  and  every- 
thing thereafter,  retentive  memory  reduced,  imagination 
impaired,  nightmares  (awaking  with  a  start). 

A  few  days  later  he  was  able  to  pronounce  his  name  with 
difficulty  and  to  say  yes  and  no.     February  4  there  was  an 


454  SHELL-SHOCK:    NATURE  AND  CAUSES 

appendicular  crisis,  whereupon  mutism  became  absolute 
again  and  lasted  into  May,  despite  suggestive  therapy. 

May  10,  improvement  in  memory  for  things  before  the 
accident  grew  better,  nightmares  had  become  less  frequent, 
the  jactitation  had  continued. 

There  was  no  neuropathic  predisposition  in  this  case  except 
infantile  convulsions  in  two  sisters,  followed  by  nervous  crises 
in  one. 

Re  appendicular  crisis,  which  was  the  occasion  of  a  relapse 
in  mutism,  see  remarks  under  relapses  under  Case  292. 

Re  mutism,  Babinski  counts  mutism,  hysteria  major,  and 
rhythmic  chorea  as  so  characteristically  hysterical  that  no 
nervous  disturbance  of  an  organic  nature  can  resemble  them. 
The  description  of  hysterical  mutism  is  due  to  Charcot. 
According  to  Babinski,  mutism  is  just  as  curable  as  hysterical 
deafness,  and  perhaps  more  curable.  Yet  mutism  persists 
unchanged  for  many  months  unless  it  is  treated  properly  by 
some  form  of  suggestion.  "It  may  be  almost  said  that  a 
subject  suffering  from  speech  defect,  who  nevertheless  suc- 
ceeds in  making  other  people  understand  by  all  sorts  of 
varied  and  expressive  gestures  the  circumstances  of  his  condi- 
tion, is  a  hysterical  mute  and  not  an  aphasic."  According  to 
Babinski,  no  true  case  of  hysterical  aphasia  has  been  pub- 
lished since  the  beginning  of  the  war;  all  the  cases  have  been 
cases  of  mutism. 


SHELL-SHOCK:    NATURE  AND   CAUSES  455 


Shell  explosion;  fainting:  Hysterical  crises  of 
emotion ;  fright  at  a  frog  in  the  garden.  Hereditary 
and  acquired  neuropathic  taint. 


Case  331.     (Claude,  Dide  and  Lejonne,  April,  1916.) 

A  lieutenant,  28  (mother  nervous;  father  had  nervous 
spells  at  fifteen ;  patient  himself  nervous  as  a  child) ,  was  under 
a  great  moral  strain  at  the  outbreak  of  war,  and  was  utterly 
exhausted  in  a  hard  battle  that  lasted  more  than  twenty-four 
hours. 

A  shell  burst  near  him  September  25  at  the  Somme,  where- 
upon he  fainted.  He  was  evacuated  to  Amiens  for  three 
weeks;  kept  his  bed;  somnambulistic;  subject  to  nervous 
crises. 

He  passed  to  the  hospital  of  Ferte-Bernard  for  a  month, 
the  crises  becoming  more  frequent.  He  was  sent  to  a  con- 
valescent d6p6t  for  three  days,  thence  for  three  months  to 
La  Plisse;  got  better;  lived  at  home,  but  went  to  a  show 
where  they  played  the  Marseillaise,  was  profoundly  moved 
thereby,  and  had  more  crises;  accordingly  went  back  under 
medical  care  and  finally  to  his  depot,  where,  upon  seeing  his 
old  comrades,  he  had  more  crises,  and  was  finally  evacuated 
to  the  neurological  center  of  the  Eighth  Region. 

He  there  seemed  mistrustful  when  asked  to  tell  his  story. 
There  was  a  noise  of  cannon,  whereupon  he  got  up,  ran  in  all 
directions  in  the  garden,  bumping  into  trees  in  the  greatest 
terror,  yelling,  "There  they  are !";  gesticulating,  soliloquizing: 
"Bomb!  Shell!  Bayonet!"  His  pulse  was  rapid.  After  he 
was  calmed  down,  he  began  to  talk  again  in  a  very  clear, 
distinct,  somewhat  tremulous  voice.  A  metallic  sound  made 
him  shudder  and  cry  out,  "The  drums!"  and  another  scene 
of  rushing  about  followed. 

In  the  consulting  office  he  wept.  Battle  dreams  and  night- 
mares, soliloquies  and  terror,  seminal  losses,  occurred  during 
the  next  few  days. 

August  4,  while  alone  in  the  garden,  he  heard  a  noise,  went 
toward  it  and  spied  a  frog,  whereupon  he  had  another  crisis 


456  SHELL-SHOCK:    NATURE  AND   CAUSES 

of  fear  and  emotion.  He  got  another  lieutenant,  and  both 
returned,  sticks  in  hand.  Pointing  to  a  hole  in  the  earth, 
Lieutenant  A.  said,  "Trenches!  There  they  are!"  "What? 
WTio?"  said  Lieutenant  B.  "The  Boches!"  said  Lieutenant 
A.  Whereupon  Lieutenant  B  also  saw  them  and  cried  out 
bravely,  "Go  away!'  However,  the  second  lieutenant  im- 
mediately saw  that  he  had  been  the  subject  of  suggestive 
hallucination. 

Fifteen  days  of  calm  followed,  during  which  the  lieutenant 
became  more  sociable  and  grew  better  having  no  more 
crises. 

Four  other  cases  of  "  hysteroemotive  nature  "  are  reported 
by  Claude,  all  of  them  showing  a  special  constitutional  basis 
before  the  war.  In  the  differential  diagnosis,  alcoholism, 
cyclothymia,  obsessive  psychosis  and  occasionally  systema- 
tized delusional  psychosis  may  be  considered.  There  were 
occasional  stereotypical  features  in  the  cases,  but  of  a  very 
fugitive  nature.  Dementia  praecox  is  hardly  to  be  con- 
sidered. 

Re  "hysteroemotive"  cases,  Babinski  holds  that  the  claim 
of  emotion  as  a  single  factor  capable  of  causing  hysteria  by 
itself,  is  a  false  claim.  To  be  sure,  the  patients  themselves 
may  give  accounts  which  lead  to  the  idea  of  an  emotional 
hysteria.  Dide,  one  of  the  authors  of  the  above  case,  states 
that  functional  disorders  occur  only  in  subjects  whose  emo- 
tional tone  has  been  relaxed.  The  heaviest  bombardments 
are  not  in  line  to  produce  these  disorders  when  the  morale 
of  the  troops  is  good.  The  bloodiest  affairs  may  leave  no 
single  case  of  nervous  disorder  when  the  morale  is  good. 
Dide  found  in  a  whole  year's  work  but  a  single  functional 
case,  — an  oniric  delirium,  following  a  trench  mortar  explo- 
sion. Roselle  and  Oberthiir  also  state  on  the  basis  of  in- 
tensive experience,  that  large  projectiles  do  not  cause  any 
intensive  emotional  reactions.  Clunet's  observations  upon 
the  shipwrecked  La  Provence  II,  quoted  by  Babinski,  run  In 
the  same  direction.  It  will  be  noted  that  the  five  cases  called 
"hysteroemotive"  showed  a  special  constitutional  basis 
antebellum. 


SHELL-SHOCK:    NATURE   AND  CAUSES  457 


War  strain;  slight  wound;  burials;  shell-shock: 
Neurosis  with  anxiety ;  war  dreams ;  apparent  re- 
covery.    Relapse  with  depression. 


Case  332.     (MacCurdy,  July,  1917.) 

A  man,  27  (normal  mischievous  boy,  successful  in  work, 
unmarried,  shy  with  women),  enlisted  October,  1914;  adapted 
himself  well  to  training;  at  first  enjoyed  his  work,  though 
later  bored  with  routine;  and  in  February,  191 5,  went  to  the 
firing  line  in  France.  The  first  shell-fire  experience  made 
him  break  into  a  cold  sweat  with  fear  and  slowed  him  down 
for  a  time.  However,  he  enjoyed  the  active  operations  until, 
after  eight  months  In  the  trenches,  he  was  invalided  home  with 
nephritis.  After  four  months'  convalescence  he  was  recom- 
mended for  a  commission,  obtained  after  two  months'  training. 
After  two  further  months  in  the  regimental  dep6t,  he  went 
back  to  France  as  lieutenant  in  June,  191 6,  plunging  Into  four 
months  of  heavy  fighting  on  the  Somme,  in  which  he  was 
wounded  slightly  once  and  was  one  day  burled  three  times  by 
earth  from  shell  explosion.  The  last  time  he  was  buried  he 
was  unconscious  for  ten  minutes  and  was  relieved  for  three 
days.  He  got  frequently  knocked  out  for  short  periods  by 
shell  concussion. 

At  the  end  of  October,  191 6,  he  was  sent  to  the  Ypres  section, 
where  he  worked  with  a  pioneer  battalion  that  buried  many 
dead.  After  a  month  of  this  pioneer  work  he  became  mildly 
depressed ;  fatigue  set  in,  and  now  for  the  first  time  he  began 
to  jump  nervously  when  the  shells  came  over.  To  counteract 
this  nervousness  he  began  to  drink  and  in  a  fortnight  de- 
veloped insomnia.  The  Somme  front  scenes  kept  constantly 
in  mind  as  he  tried  to  sleep.  He  felt  as  if  he  had  to  go  up  to 
the  trenches  next  day  and  that  he  did  not  want  to  go.  There 
were  hypnagogic  hallucinations  of  trenches  and  shells,  recog- 
nized as  imaginary  and  productive  of  no  fear.  Week  by  week 
he  became  more  nervous,  became  unable  to  locate  shell  falls, 
and  felt  as  if  they  were  all  coming  at  him.     Early  in  191 7  he 


458  shell-shock:  nature  and  causes 

had  taken  heavily  to  drink  and  grew  greatly  fatigued  in  the 
struggle  to  prevent  betraying  his  fear  to  his  men.  The  horror 
at  bloodshed,  to  which  he  had  long  since  become  accustomed, 
reappeared.     He  actually  wished  that  he  might  be  killed. 

He  carried  on  until  March,  when  one  day  on  a  raid  seven 
men  were  killed  around  him  and  he  was  immediately  there- 
after buried.  He  reported  sick  and  was  found  to  be  some- 
what febrile.  He  carried  on  for  two  more  days;  had  to 
report  sick  again;  was  sent  to  hospital  and  for  two  or  three 
weeks  had  bad  headaches  back  of  the  eyes  and  a  sleep  inter- 
rupted by  sudden  wakings  wdth  a  start.  Nightmares  now 
began  for  the  first  time.  They  dealt  with  the  Somme  front, 
merciless  shelling  coming  nearer  and  nearer.  Finally,  he 
would  wake  with  a  shriek  when  a  shell  landed  on  top  of  him. 
In  the  day  time  any  noise  would  be  interpreted  as  a  shell. 
Hypnagogic  hallucinations  of  Germans  entering  the  room 
appeared.  After  a  little  over  a  week  in  French  hospitals  he 
was  transferred  to  London;  grew  better;  was  sent  to  a 
hospital  in  the  country  where  outdoor  exercise  and  recreation 
helped  him. 

Two  weeks  later  the  death  of  one  of  his  best  friends  de- 
pressed him  a  good  deal.  He  failed  in  an  attempt  to  sing  at 
a  concert,  and  then  grew  much  worse,  with  the  old  dreams 
every  night  and  hypochondriacal  complaints  of  sweats  and 
loss  of  weight.  He  was  convinced  that  he  was  physically 
and  nervously  a  permanent  wreck. 

According  to  MacCurdy,  this  case  is  a  typical  case  of  war 
neurosis  of  the  anxiety  type,  except  that  a  relapse  with  de- 
pression is  somewhat  atypical. 

Re  anxiety,  Lepine  counts  trauma  as  one  of  the  most 
important  factors.  The  reduction  of  morale  in  physically 
injured  cases  may  at  times  require  their  rapid  withdrawal  to 
a  safety  zone.  The  delirium  of  the  physically  injured  some- 
times takes  on  a  melancholic  tinge.  Fatigue,  loss  of  sleep, 
and  cold  are  other  factors  of  a  physical  nature.  Among 
the  moral  factors,  Lepine  thinks  responsibility  (for  certain 
dmes  scrupuleuses)  is  hardly  less  important  than  the  factor 
of  felt  danger.  The  contacts  of  highly  cultivated  men  with 
the  rougher  soldier  element,  may  also  count,  as  well  as  the 


SHELL-SHOCK:    NATURE  AND   CAUSES  459 

separation  from  home  and  friends,  and  the  factor  of  despair 
concerning  the  ending  of  the  war. 

Re  sexual  influences,  the  factor  of  sexual  continence,  though 
it  may  have  some  importance  in  producing  morbid  anxiety, 
seems  to  have  less  importance  under  war  conditions,  when 
self-preservation  is  more  in  the  eye  than  the  sexual  life.  On 
the  whole,  the  pre-existent  emotional  constitution  (Dupre) 
is  of  greater  importance.  A  previous  wound  may  cause  a 
man  to  acquire  such  a  constitution.  Amongst  physical 
states,  hypotensives  are  candidates  for  depression;  tubercu- 
losis is  particularly  important. 

Re  MacCurdy's  case,  the  factor  of  alcoholism  was  men- 
tioned. The  importance  of  alcoholism,  Lepine  has  particu- 
larly stressed.  He  particularly  emphasizes  the  number  of 
men  who  have  taken  to  drink  to  get  over  their  emotions  and 
to  forget.  Visual  hallucinations,  angry  excitability,  sudden 
persecutory  ideas,  nocturnal  occurrence  of  the  symptoms, 
flushing  of  the  face,  suggest  alcoholism.  Some  of  the  cases 
of  encephalitis  which  are  supposed  to  be  due  to  some  un- 
known bacterium,  may  really  be  alcoholic  in  origin.  A  third 
of  Lepine's  cases  were  alcoholic;  perhaps  two-thirds  really 
alcoholic  if  one  took  into  account  the  factor  of  sensitization. 


460  shell-shock:   nature  and  causes 


Bombardment  from  airplanes :  Fear ;  suicidal 
thoughts;  oniric  delirium  ("moving  picture  in  the 
head.") 


Case  333.     (HovEN,  May,  1917.) 

A  soldier  (born  at  seven  months,  somewhat  feebleminded, 
given  to  depression,  early  victim  of  convulsions,  talking  only 
at  five  years,  with  a  history  of  once  leaving  his  father's  house 
with  suicidal  ideas  after  being  scolded,  already  invalided  In 
peace  times)  on  enlistment  remained  with  the  regiment  but 
a  few  days  and  was  then  sent  to  a  workers'  company  of 
blacksmiths. 

Toward  the  end  of  February,  191 6,  his  cantonment  was 
bombarded  by  an  airplane  escadrille.  The  patient  was  much 
frightened,  ran  away  and  hid  in  a  ditch,  felt  sick,  stopped 
eating,  wanted  to  kill  himself  and  had  to  be  evacuated  to 
Calais  and  then  to  Chateauglron. 

He  was  there  found  to  be  well  oriented,  but  depressed  and 
bewildered.  There  was  an  emotional  tachycardia.  At  night 
he  would  fall  into  a  delirium  like  the  oniric  delirium  of  Regis, 
always  dreaming  of  the  same  bombardment  scene,  saying  it 
was  like  a  moving  picture  in  his  head.  The  delirium  affected 
him  so  that  he  actually  tried  to  make  away  with  himself. 

The  dream  delirium  did  not  last  long  but  recurred  several 
times  on  very  slight  emotional  occasions.  It  was  possible  to 
excite  his  hallucinatory  dreams  experimentally  by  showing 
him  battle  pictures. 

Some  cases  of  such  delirium  develop,  according  to  Hoven, 
after  moving  picture  shows  of  battle  scenes. 

Re  oniric  delirium,  Chavlgny  states  that  mental  confusion 
and  oniric  delirium  are  the  two  forms  of  mental  disorder  that 
come  most  frequently  after  explosions.  He  believes  that  at 
least  95  per  cent  of  these  cases  are  rapidly  curable;  and.  In 
fact,  found  amongst  60  cases  observed  in  his  army  service 
that  only  two  were  so  severe  as  to  require  being  sent  to  the 
interior:  all  the  others  were  cured  in  six  days  at  the  outside. 
These  cases,  according  to  Chavlgny,  ought  to  be  treated  in 


SHELL-SHOCK:  NATURE  AND  CAUSES         46 1 

Special  wards  at  the  front  (bed,  quiet,  purgation,  baths). 
Chavigny  prearranges  slight  emotional  shock  for  these  cases 
by  talking  with  them  about  their  families.  Their  apparent 
apathy  vanishes  in  a  trice. 

Regis,  who  has  named  the  state  "oniric  delirium,"  states 
that  the  condition  never  lasts  more  than  a  fortnight,  is 
caused  by  emotional  shock,  and  occurs  in  all  cases  with 
mental  disorder  following  battle;  but  similar  hallucinatory 
conditions  have  begun  to  appear  also  amongst  alcoholics, 
in  garrison  or  at  home.  There  is  emotional  constitution  in 
most  of  these  cases.  There  is  not  so  much  evidence  of 
heredity.  Out  of  50  of  Regis'  cases,  22  had  been  wounded, 
and  28  not.  Regis  states  that  the  psychoses  are  rather  more 
apt  to  affect  men  in  the  reserve,  and  are  severest  in  officers. 
These  cases  should  not  be  committed  to  institutions,  but 
ought  to  be  treated  in  special  military  psychiatric  wards  con- 
taining separate  rooms.  Very  fine-spun  diagnosis  may  be 
necessary  now  and  again  on  account  of  the  occurrence  of 
infectious  deliria  and  phenomena  of  the  banal  psychoses  that 
may  closely  resemble  oniric  deliria. 


462  shell-shock:  nature  and  causes 


Shell-shock ;  emotion  (best  friend  mangled) :  Stupor 
with  amnesia. 


Case  334.     (Gaupp,  March,  191 5.) 

A  soldier,  23  (in  civil  life  a  turner,  of  Polish  descent,  and  of 
a  somewhat  nervous  and  easily  excitable  disposition),  early 
in  August  went  from  Strassburg  into  the  Vosges  and  Lorraine. 
August  26  a  number  of  shells  exploded  near  him.  The  troop 
was  excited  and  took  refuge  in  a  cellar.  His  best  friend  was 
torn  to  pieces  by  a  shell.  When  the  body  was  removed,  the 
man  felt  sick  and  lost  consciousness.  He  arrived  at  the  clinic 
in  Tubingen  in  a  stuporous  condition,  by  hospital  train, 
August  31,  1914.  He  walked  weakly  to  his  bed,  supported 
by  two  men,  and  lay  in  the  bed,  apathetic  and  reacting  to 
questions  only  with  a  stare.  Things  put  in  his  mouth  were 
swallowed.     He  remained  motionless. 

Next  evening  he  answered  a  low  Yes  to  a  nurse's  question 
about  eating.  A  little  afterwards,  he  said  he  supposed  he 
was  a  prisoner  in  the  enemy's  country.  A  while  later  he  got 
properly  oriented  but  still  did  not  know  how  he  had  come. 
September  2,  however,  he  was  much  clearer  and  said  he  had 
awakened  out  of  a  long  dream.  There  was  a  complete 
amnesia,  however,  from  the  moment  when  he  went  to  help 
remove  the  torn  body  of  his  friend  up  to  September  i.  Mem- 
ories became  clearer  for  the  period  before  the  shell  explosion. 
The  patient  became  very  lively,  talking  vividly  of  war 
experiences.  Imitating  the  hiss  of  shells  with  an  expression  of 
Intense  anxiety,  getting  accustomed  to  the  battle  scenes, 
saying  that  he  was  now  seeing  everything  again  as  If  real.  He 
remained  anxious  for  some  days,  complaining  of  weight  on 
his  chest  and  of  feelings  of  inner  restlessness  and  tension. 

Amnesia  for  the  period  August  26  to  September  i  re- 
mained ;  all  that  he  could  say  was  that  he  had  been  thrown 
sidewise  for  some  distance  by  the  air  pressure  of  the  shell. 

From  September  6  onwards,  he  grew  calmer  but  he  was 
still  very  labile,  given  to  lively  Imaginings  and  emotion.  By 
mid  September  he  could  be  discharged  for  garrison  duty. 


SHELL-SHOCK:    NATURE  AND  CAUSES  463 


Emotional  shock ;  shooting  a  comrade :  Horror, 
sweat,  stammer,  recurrent  nightmare.  Improve- 
ment on  "tracing  back."  Brief  recrudescence  on 
death  of  child. 


Case  335.     (Rows,  April,  1916.) 

A  man  after  a  charge  was  placed  on  outpost  duty.  It  was 
dark,  and  he  was  in  a  state  of  considerable  tension.  He  heard 
a  noise  which  he  thought  came  from  somewhere  in  front  of 
him.  Suddenly  the  space  around  him  was  illuminated  by  a 
flare  of  light,  and  he  saw  a  man  crawling  over  the  bank. 
Without  challenging,  he  fired  and  killed  the  man.  Next 
morning,  he  found  to  his  horror  that  he  had  killed  a  wounded 
Englishman,  who  had  advanced  beyond  his  comrades  and 
was  crawling  back. 

A  physical  expression  of  horror,  together  with  an  intense 
sweating  and  a  very  marked  stammer,  persisted  for  months. 
At  the  same  time,  he  was  tormented  with  a  fearful  nightmare, 
and  in  his  sleep  he  was  heard  to  say,  "It  was  an  accidental 
shot,  sir;  yes,  Major,  it  was  not  my  fault."  In  the  day  time, 
also,  his  attention  was  concentrated  on  the  memory  of  the 
incident,  so  that  "I  cannot  forget  it  no  matter  how  I  sky- 
lark." Carrying  his  story  back  to  this  trying  time  led  to 
his  recounting  his  terrible  secret,  and  a  marked  improvement 
followed.  The  physical  signs  of  the  intense  emotion  grad- 
ually disappeared.  The  vividness  of  the  dreams  dimin- 
ished, and  his  attention  was  less  concentrated  on  the  one 
subject.  It  is  interesting  to  note  that  the  production  of  a 
marked  emotional  state  by  the  death  of  one  of  his  children 
led  to  a  recrudescence  of  his  former  symptoms :  an  expression 
of  "horror  and  the  stammer."  But  they  disappeared  again 
in  a  short  time. 


464  SHELL-SHOCK:    NATURE  AND   CAUSES 


Emotional  shock :  Phobias. 


Case  336.     (Bennati,  October,  1916.) 

An  Italian  corporal  in  the  infantry,  a  robust  man  of  a  well- 
to-do  family,  took  a  good  deal  of  pleasure  in  the  war  life. 
One  day  a  comrade  was  injured  by  a  missile  of  some  sort,  and 
died  almost  immediately.  This  comrade,  after  being  hurt, 
had  thrown  himself  against  the  corporal,  who  was  asleep  at 
the  time.  He  woke  up  sharply  and  immediately  felt  sick. 
His  status  was  one  of  great  terror,  lacrimation,  lack  of 
spontaneity,  and  insomnia.  He  would  wake  up  from  sleep 
and  start  from  a  terrible  dream.  He  had  a  number  of  phobias 
and  was  especially  interested  in  other  persons  who  had  the 
same  sort  of  mental  state  as  himself.  He  was  in  a  state 
noted  by  Bennati  as  one  of  "emotional  anaphylaxis"  to 
various  events  around  him.  There  was  a  horizontal  nystag- 
mus, the  Mannkopf  sign  was  positive  (87-72),  Thomayer 
90-114,  Erben  114-90.  There  was  a  slight  tendency  to 
dizziness  when  the  Erben  movements  were  made. 


SHELL-SHOCK:    NATURE   AND   CAUSES  465 


Shell-shock ;  fright :  loss  of  consciousness  next  day : 
GeneraUzed  tremors;  ''somebody  above  with  a 
mallet." 


Case  337.     (Wiltshire,  June,  1916.) 

A  sapper  of  19,  with  a  nervous  mother,  had  had  an  attack 
two  years  before  his  war  neurosis,  of  a  somewhat  similar 
nature.  This  former  attack  had  been  caused  by  overwork; 
there  had  been  no  accident  or  fright,  but  the  man  had  been 
unable  to  work  for  five  months. 

At  the  front,  he  had  been  well  up  to  ten  days  before  obser- 
vation. In  a  dugout  a  shell  had  pitched  on  top  of  the  bank, 
followed  by  another  shell  bursting  in  front.  There  was  a 
slight  falling  in  of  the  dugout  but  no  special  damage. 

The  patient  carried  on  that  night  but  reported  sick  next 
morning,  feeling  queer  and  shaking  slightly  above  the  waist. 
He  remembered  getting  half-way  down  the  road  to  see  the 
M.  O.,  but  nothing  more  until  he  came  to  in  the  dressing 
station  (perhaps  2|  hours  later).  After  two  days  in  hospital, 
he  was  transferred  to  a  convalescent  camp,  and  then  admitted 
to  another  hospital.  He  complained  of  twitching  and  slight 
frontal  headache ;  funny  feelings  at  night  prevented  his  going 
to  sleep.  Thus:  "A  man  was  over  my  head  with  a  mallet, 
going  to  hit  me."  There  was  a  dream  of  "somebody  above 
me  all  the  time."  Both  arms,  head,  and  tongue  were  in  a 
state  of  constant  tremor,  and  there  were  jerky  movements  of 
the  legs.  There  was  some  spasm  of  the  right  leg.  Both  legs 
went  into  violent  tremor  on  examination,  and  during  examina- 
tion there  was  free  perspiration. 

Re  tremors,  all  sorts  of  tremors  of  unknown  nature  are 
apt  to  get  the  designation  hysterical.  Melge  believes  that 
the  Shell-shock  tremors,  which  are  apt  to  be  very  persistent, 
are  very  possibly  due  to  changes  in  the  nervous  system. 
Ballet  has  noted  how  the  tremors,  as  in  the  above  case, 
are  often  associated  with  expressions  of  fear.  Now  and  then 
there  Is  an  obsessive  disorder  dubbed  tremophobia  by  Melge, 
which  produces  a  vicious  circle.     Tremors  lead  to  obsessions, 


466  SHELL-SHOCK:    NATURE  AND   CAUSES 

and  the  obsessions  in  turn  exaggerate  the  tremors.  These 
Shell-shock  tremors  are  apparently  not  related  to  (though 
they  may  need  differential  diagnosis  from)  such  conditions 
as  paralysis  agitans,  multiple  sclerosis,  hyperthyroidism,  cere- 
bellar disease,  neurosyphilis,  and  alcoholic  or  other  intoxica- 
tion. 

Roussy  and  Lhermitte  distinguish  the  tremors  into  (a) 
atypical  ones;  that  is,  disorderly,  irregular  movements  seem- 
ingly determined  by  the  subject's  caprice;  and  (b)  typical 
tremors,  such  as  those  found  In  the  well-known  nervous 
diseases  and  presumably  imitated  in  hysteria  from  these  well- 
known  diseases.  Generalized  atypical  tremors  are,  as  a  rule, 
combined  with  a  variety  of  other  Shell-shock  symptoms,  and 
often  exhibit  a  sort  of  mimicry  of  fear. 


shell-shock:  nature  and  causes  467 


Shell-shock;  burial-work:   Amnesia.     Shell  whis- 
tling conditions  idea  of  something  nasty. 


Case  338.     (Wiltshire,  June,  191 6.) 

A  private,  19,  in  the  R.  A.  M.  C,  was  sent  in  with  a  field 
ambulance  note  as  follows: 

"Private  was  close  to  a  shell  which  burst 

among  a  company  standing  in  the  road,  killing  20  and 
wounding  20  others.  He  worked  well  in  assisting  the 
wounded,  and  then  proceeded  to  clear  up  the  fragments 
of  the  killed.  Whilst  doing  this,  he  suddenly  lost  his 
mental  balance  and  has  been  in  his  present  state  nearly 
24  hours.     He  has  been  given  bromides." 

An  M.  O.  attached  to  the  same  ambulance  wrote: 
"This  man  is  suffering  from  mental  shock  caused  by 
having  to  clear  away  the  remains  of  a  number  of  men 
killed  by  a  shell.  He  does  not  recognize  his  friends, 
and  at  frequent  intervals  has  periods  of  terror,  exclaim- 
ing, 'Cover  it  up.'  He  is  sleepless  (without  drugs); 
he  takes  food  badly.  He  Is  possibly  suicidal  or  may 
become  so." 

According  to  the  patient  himself,  he  had  been  quite  well 
for  four  months  at  the  front.  He  was  on  the  La  Bassee  Road 
with  the  troops  after  a  day  or  two  of  heavy  work  under  shell 
fire.  "And  I  remember  the  flash  of  some  shot  and  a  shell 
burst  I  think,  and  I  can't  remember  anything  more.  I  awoke 
in  the  morning,  in  the  train  "  (48  hours  later).  "  I  can  only 
remember  men  calling  out."  He  complained  of  a  feeling  in 
the  head,  as  if  expecting  something.  "Something  seems  to 
be  coming,  —  as  if  something  was  going  to  happen,  —  some- 
thing nasty,  whenever  I  hear  anything  like  the  whistling  of  a 
shell  coming  towards  me."  This  patient  was  without  tremor 
and  was  physically  normal.  So  far  as  the  patient's  own 
story  went,  the  case  might  well  be  regarded  as  one  due  to 
physical  concussion,  but  the  notes  of  the  medical  officers  give 
evidence  of  a  psychic  element. 


468  shell-shock:   nature  and  causes 


Depression  with  suicidal  thoughts  after  witnessing 
death  of  comrade. 


Case  339.     (Steiner,  October,  1915.) 

A  farmer,  52,  volunteered  and  was  put  in  charge  of  a 
drinking-water  still.  He  had  never  been  ill  nor  was  there 
any  nervous  or  mental  disease  in  his  family.  From  the  end 
of  August  he  was  frequently  under  shell  fire,  but  the  only 
effect  thereof  was  a  somewhat  poorer  sleep  than  normal. 

December  14,  1914,  a  young  comrade,  a  volunteer,  wanted 
to  clean  his  dirty  kettle  at  the  drinking-water  still.  The 
farmer  later  described  this  volunteer  as  a  young  fellow  "like 
milk  and  blood  "  (as  we  might  say,  "like  peaches  and  cream  ") 
and  as  the  handsomest  young  man  he  had  ever  seen  in  the 
war.  The  rules  forbade  such  use  of  the  still,  and  young 
"  milk-and-blood  "  was  told  to  go  down  to  the  brook,  and 
then  come  back  and  get  the  distilled  water.  The  young  man 
complied,  but  while  at  the  brook  he  was  shot  and  killed  in 
full  sight  of  the  farmer. 

The  farmer  grew  much  excited  and  trembled  all  over. 
Thereafter  he  could  not  eat  or  sleep;  he  reproached  himself, 
although  he  knew  he  had  acted  quite  correctly;  wished  he 
had  been  in  the  place  of  this  comrade;  and  had  suicidal 
thoughts.  He  was  deeply  depressed,  wept  easily,  and  showed 
manual  tremor.  Steiner  terms  the  farmer's  account  of  the 
person  of  the  deceased  "reactive  idealization."  After  a 
week  there  was  considerable  improvement.  B.  was  sent  back 
to  work,  which  he  felt  would  be  beneficial.  He  was  put  in 
less  dangerous  surroundings,  and  this  also  had  a  good  effect. 


SHELL-SHOCK:    NATURE   AND   CAUSES  469 


Marching  and  battles :  Neurasthenia? 


Case  340.     (BoNHOEFFER,  January,  191 5.) 

A  subaltern  had  been  treated  before  the  war  for  nervous- 
ness, dizziness,  and  "  mattigkeit  "  (convulsions  in  infancy), 
but  proved  himself  a  good  soldier,  having  gotten  his  rank  after 
the  first  period  of  practice. 

He  was  in  three  battles  in  Belgium,  but  on  the  march  one 
day  suddenly  had  a  spell  of  weakness  and  is  said  to  have  had 
convulsions.  There  was,  however,  no  biting  of  the  tongue, 
and  no  enuresis.  After  a  week  in  the  field  hospital,  he  was 
sent  back  to  Berlin  where  he  had  some  somatic  feelings  of 
anxiety  without  subjective  disturbance  or  any  disorders  of 
consciousness  except  a  certain  amount  of  inhibition;  he  was 
sleepless  and  hypersensitive,  cried  easily,  and  was  appre- 
hensive on  being  touched;  he  winked  violently  on  examina- 
tion of  his  eyes,  and  while  being  tested  for  reflexes  made  violent 
contractions  of  a  semi-voluntary  nature. 

After  four  days  in  bed,  which  was  a  prescription  hard  to 
carry  out  at  first  on  account  of  the  anxiety  sensations,  these 
sensations  disappeared,  and  at  the  same  time  the  fears. 
Weight  began  to  increase;  memories  returned,  except  that 
even  upon  recovery  he  could  not  remember  that  he  had  ever 
had  any  true  subjective  feelings  of  fear.  He  was  discharged 
19  days  later,  desirous  of  going  back  into  the  field. 

The  peculiar  absence  of  subjective  feelings  of  fear  in  this 
case  is  something  like  what  Awtokratow  reported  from  the 
Russo-Japanese  War,  terming  them  neurasthenic  psychoses. 

Re  neurasthenia,  Babinski  believes  that,  by  means  of  his 
logical  dismembering  of  the  old  hysteria  concept,  he  has 
shown  that  the  exhaustion  phenomena  at  the  bottom  of 
neurasthenia  are  precisely  these  that  cannot  be  cured  by 
suggestion.  There  are  numerous  cases  in  which  hysteria  and 
neurasthenia  are  combined.  From  these  combined  cases, 
suggestion  causes  the  hysterical  or  pithiatic  symptoms  to  be 
removed. 


^70  '  SHELL-SHOCK:    NATURE   AND   CAUSES 


English  schoolmaster's  account  of  his  war  dreams. 


Case  341.     (AIoTT,  February,  1918.) 

A  sergeant,  who  had  been  a  schoolmaster,  was  asked  to 
write  down  his  dreams  by  Captain  W.  Brown,  who  had  some- 
times charge  of  Mott's  cases  at  the  Maudsley  Hospital. 
The  first  dream  was  as  follows: 

"I  appeared  to  be  resting  on  the  roadside  when  a 
woman  (unknown)  called  me  to  see  her  husband's 
(a  comrade)  body  which  was  about  to  be  buried.  I 
went  to  a  field  in  which  was  a  pit,  and  near  the  edge 
four  or  five  dead  bodies.  In  a  hand-cart  nearby  was 
a  legless  body,  the  head  of  which  was  hidden  from  sight 
by  a  slab  of  stone.  [He  had  seen  a  legless  body,  which 
was  covered  with  a  mackintosh  sheet,  which  he  re- 
moved.] On  moving  the  stone  I  found  the  body  alive, 
and  the  head  spoke  to  me,  imploring  me  to  see  that  it 
was  not  buried.  Burial  party  arrived,  and  I  was  my- 
self about  to  be  buried  with  legless  body  when  I  awoke." 
The  second  dream  was  as  follows: 

"After  spending  an  evening  with  a  brother  (dead  1 1 
years  ago)  I  was  making  my  way  home  when  a  violent 
storm  compelled  me  to  take  shelter  in  a  kind  of  culvert, 
which  later  turned  into  a  quarry,  situated  between  two 
houses.  Men  were  doing  blasting  operations  in  the 
quarry,  and  whilst  watching  them  I  saw  great  upheavals 
of  rock,  and  eventually  the  building  all  around  collapsed 
(explosion  of  a  mine) .  Amongst  the  debris  were  several 
mutilated  bodies,  the  most  prominent  of  which  was 
legless.  I  tried  to  proceed  to  the  body,  but  found  that 
I  was  myself  pinned  down  by  masonry  which  had  fallen 
on  top  of  me.  As  I  struggled  to  get  free  the  whole 
scene  appeared  to  change  to  a  huge  fire,  everything 
being  enveloped  in  flames,  and  through  the  flames  I 
could  still  see  the  legless  body  which  now  bore  the  head 
oj  my  wife,  who  was  calling  for  me.  I  was  struggling 
to  get  free  when  my  mother  seemed  to  be  coming  to  my 
assistance,  and  I  awoke  to  find  the  nurses  and  orderlies 
standing  over  me." 
It  appears  that  the  patient  had  been  shouting  in  his  sleep, 
beginning  in  a  low  voice  and  gradually  becoming  louder  until 
at  last  he  was  shrieking.     The  legless  body  occurred  in  all 


SHELL-SHOCK;  NATURE  AND  CAUSES         47 1 

his  dreams;  the  sight  of  this  had  evidently  produced  a  pro- 
found emotional  shock.  He  had  worried  a  great  deal  about 
his  wife,  who  was  much  younger  than  himself,  so  that  we  have 
this  incongruous  association  of  the  legless  body  and  the  head 
of  his  wife  calling  him;  finally,  what  more  natural  than  the 
mother  to  come  to  his  help.  The  emotional  complex  is  not 
incongruous  in  this  dream,  for  fear  is  linked  up  with  the 
tender  emotion. 

Re  war  dreams,  see  remarks  under  Case  333  concerning 
oniric  delirium.  Roussy  and  Lhermitte  say  that  emotion 
and  concussion  are  the  causal  factors;  but  in  a  case  like  341 
we  have  persistent  war  dreams  of  the  same  general  nature. 
Such  a  case  as  Mott's  would  not  be  regarded  as  one  of  oniric 
delirium,  for  the  patient  is  not  living  throughout  the  day  in 
a  dream,  but  merely  has  certain  set  dreams.  The  true 
oniric  delirium  cases  may  lead  to  fugues  of  medicolegal  im- 
portance. Mott's  conception  is  that  the  terrifying  experi- 
ences that  come  to  light  in  the  dreams  are  repressed  by  the 
conscious  activity  of  the  mind  in  the  waking  state.  For  this 
process,  the  phrase  psychic  trauma  might  be  used.  Rows 
speaks  of  a  prolongation  of  mental  disorder  through  memo- 
ries which  get  revived  in  dreams.  The  memories  of  past 
and  recent  events  pile  up  on  one  another.  Elliot  Smith 
remarks  on  the  number  of  cases  in  which  the  dreams  show  a 
coalescence  and  blending  of  episodes  alien  to  the  war.  Re 
such  combinations,  see  Case  342  of  Rows,  below. 


472  SHELL-SHOCK:    NATURE   AND   CAUSES 


Trench  experience:  War  dreams,  shifting  to  sex 
dreams.  Recovery  on  giving  the  patient  an  insight 
into  the  nature  of  his  dreams. 


Case  342.     (Rows,  April,  1916.) 

A  patient  broke  out  of  a  hospital  after  being  refused 
permission  to  leave  the  grounds.  He  grew  much  depressed 
and  said  he  had  been  disgraced  and  would  commit  suicide 
rather  than  bring  disgrace  on  his  family.  Investigation  into 
this  emotional  outburst  showed  that  his  father  had  deserted 
the  family,  that  he  had  gotten  into  prison,  and  "tainted  me." 
The  patient  was  worried  also  about  an  idea  of  loss  of  sex 
power,  gathered  from  a  book  by  a  quack  doctor,  read  years 
ago.  It  appeared  also  that  this  doctor  had  advertised  a 
special  bread  and  special  medicine  which  would  preserve  the 
nervous  system,  and  that  for  years  the  patient  had  fed  him- 
self and  his  family  with  the  bread  and  medicine.  When  the 
true  state  of  affairs  was  shown  to  the  patient,  his  restlessness 
at  night  disappeared.  The  mental  condition  of  this  man 
in  fact  became  practically  normal,  and  the  marked  tic  of 
facial  muscles  and  the  general  tremulousness  of  the  man 
disappeared. 

It  is  of  note  that  this  man's  dreams  began  with  a  terrible 
incident  in  the  trenches  and  then  shifted  to  sex  acts.  He 
woke  to  find  the  clothes  disturbed. 

This  is  an  example  of  hallucinations  dispelled  by  trac- 
ing them  to  their  source,  and  giving  the  patient  a  clear 
insight  into  their  nature. 

According  to  Ballet  and  de  Fursac,  after  the  acute  phase 
of  stupor  and  excitement  with  hallucinations  and  delirium 
passes,  the  patient  remains  a  depressed  and  psychasthenic 
subject.  In  this  psychasthenia  we  find  inhibitory  phenom- 
ena, hyperemotionalism,  and  over-imagination.  Amongst 
the  inhibitory  phenomena  are  many  of  the  hysterical  effects. 
The  hyperemotionalism  yields  anxiety,  worry,  tremors,  res- 
piratory and  vasomotor  disorder,  dizziness,  convulsions. 
The  third   main  disorder   of   the   psychasthenic   state   into 


SHELL-SHOCK:    NATURE   AND   CAUSES  473 

which  the  patient  relapses  is  over-imagination,  whereunder 
we  find  bad  dreams  (bombardments,  drum-beating,  corpses, 
attacks),  somnambulistic  hallucinatory  episodes.  It  is  these 
hyperemotional  and  hyperfantastic  features  that  distinguish 
the  Shell-shock  syndrome  from  ordinary  psychasthenic  states. 
Re  the  sex  element  in  this  case,  see  remarks  under  pre- 
ceding case  (341)  and  also  Lepine  on  the  sex  factor  (Case 
332).  Rows  believes  that  those  cases  which  do  not  recover 
after  a  short  period  of  rest  and  quiet  in  hospital  are  cases  in 
which  there  is  some  emotional  state  based  upon  the  constant 
intrusion  of  the  memory  of  some  past  event.  The  physical 
expression  of  the  emotion  of  fear  or  terror  may  persist  for  a 
long  time  quite  unchanged  and  be  proved  to  be  due  to  this 
old  factor. 


474  SHELL-SHOCK:    NATURE  AND   CAUSES 


Emotional  shock:  Recurrent  dreams  of  war  and 
peace  incidents.  Recovery  followed  tracing  the 
dreams  to  their  origin. 


Case  343.     (Rows,  April,  191 6.) 

A  soldier  and  a  comrade  were  carrying  a  pail  of  water  to 
the  trenches.  It  was  very  cold  and  they  set  down  the  pail 
in  order  to  warm  their  hands.  The  comrade  placed  his  hand 
against  the  man's  cheek  and  said,  "That  hand  is  cold."  At 
that  moment  he  was  shot  dead. 

This  incident  was  involved  not  only  in  dreams  at  night,  but 
in  the  daytime  too,  if  he  vrere  quiet  and  closed  his  eyes,  he 
could  feel  the  cold  hand  against  his  face. 

He  was  troubled  at  the  same  time  by  another  dream,  in 
which  he  ran  down  a  narrow  lane  at  the  bottom  of  which  there 
was  a  well.  He  dipped  his  hands  into  the  water,  but  on  with- 
drawing them,  he  was  horrified  to  find  they  were  covered 
with  blood.  This  dream  was  connected  with  a  love  affair, 
in  which  a  good  friend  interfered  and  angered  him  so  much 
that  he  attacked  him  when  next  they  met.  He  left  him  on 
the  ground  so  injured  that  it  was  necessary  to  take  him  to  a 
hospital.  The  patient  became  anxious  as  to  what  the  result 
might  be  and  left  the  district.  He  traveled,  but  never  heard 
whether  his  victim  had  died. 

When  these  two  dreams  were  traced  back  to  their  origin 
they  disappeared :  the  patient  made  a  rapid  recovery  and  was 
able  afterwards  to  bear  a  severe  trial  satisfactorily. 

See  remarks  under  Case  342. 


SHELL-SHOCK:    NATURE   AND   CAUSES  475 


War  dreams,  including  hunger  and  thirst. 


Case  344.     (MoTT,  February,  1918.) 

{Recorded  Dream  of  a  Second  Lieutenant.) 

"During  the  five  days  spent  in  the  village  of  Roeux  I  was 
continually  under  our  own  shell  fire  and  also  continually 
liable  to  be  discovered  by  the  enemy,  who  was  also  occupying 
the  village.  Each  night  I  attempted  to  get  through  his  lines 
without  being  observed,  but  failed.  On  the  fourth  day  my 
sergeant  was  killed  at  my  side  by  a  shell.  On  the  fifth  day 
I  was  rescued  by  our  troops  while  I  was  unconscious.  During 
this  time  I  had  had  nothing  to  drink  or  eat,  with  the  exception 
of  about  a  pint  of  water. 

"  At  the  present  time  I  am  subject  to  dreams  in  which  I  hear 
these  shells  bursting  and  whistling  through  the  air.  I  also 
continually  see  my  sergeant,  both  alive  and  dead,  and  also 
my  attempts  to  return  are  vividly  pictured.  I  sometimes 
have  in  my  dreams  that  feeling  of  intense  hunger  and  thirst 
which  I  had  in  the  village.  When  I  awaken  I  feel  as  though 
all  strength  had  left  me  and  am  in  a  cold  sweat. 

"  For  a  time  after  awaking  I  fail  to  realize  where  I  am  and 
the  surroundings  take  on  the  form  of  the  ruins  in  which  I 
remained  hidden  for  so  long. 

"  Sometimes  I  do  not  think  that  I  thoroughly  awaken,  as  I 
seem  to  doze  off,  and  there  are  the  conflicting  ideas  that  I  am 
in  the  hospital,  and  again  that  I  am  in  France. 

"  During  the  day,  if  I  sit  doing  nothing  in  particular  and  I 
find  myself  dozing,  my  mind  seems  to  immediately  begin  to 
fly  back  to  France. 

"  A  dream  that  keeps  on  coming  up  in  my  mind  is  one  that 
brings  back  a  motor  accident  I  had  about  six  years  ago,  which 
gave  me  a  severe  nervous  shock.  I  had,  of  course,  entirely 
forgotten  about  it,  except  when  in  a  motor,  when  I  always 
thought  of  it. 

"  Of  the  fifth  day  I  have  absolutely  no  recollections." 

This  is  the  one  instance  in  which  a  man  has  dreamt  the 
experience  of  hunger  and  thirst  in  addition  to  battle  ex- 
perience. 


476  SHELL-SHOCK:    NATURE  AND  CAUSES 


Olfactory  dreams :  Hysterical  vomiting. 


Case  345.     (Wiltshire,  June,  1916.) 

A  lieutenant  in  the  infantry  (mother,  of  a  nervous  dis- 
position) had  been  at  the  front  for  3I  months  when  he  started 
vomiting  everything  he  ate. 

He  was  transferred  a  fortnight  later  to  a  base  hospital  as 
"gastritis."  Physical  examination  proved  negative,  but  the 
man  complained  of  his  ner^'^es.  He  slept  badly  owing  to 
trench-life  dreams,  from  which  he  would  wake  in  a  sweat. 
He  was  quite  unwilling  to  refer  to  these  dreams. 

In  point  of  fact  he  had  had  to  supervise  the  burial  of  many 
decomposing  bodies,  after  which  he  had  been  haunted  "by 
that  awful  smell  of  the  dead."  Then  developed  states  of 
abstraction,  in  which  he  went  over  and  over  the  burying 
experience.     He  cried  by  himself. 

It  seems  that  the  vomiting  was  secondary  to  hysterical 
hallucinations. 

Re  affections  of  smell  and  taste,  Roussy  and  Lhermitte 
remark  that  they  are  rare  following  shock  or  trauma  in  war. 
Medical  suggestion  may  produce  a  hemiageusia  or  a  hemi- 
anosmia.  Mott's  case  above  (344)  showed  unusual  dreams 
with  hunger  and  thirst.  For  another  olfactory  case,  see 
Case  510  (Rivers)  in  the  Treatment  Section  of  the  book,  a 
case  in  which  Rivers  was  able  to  find  no  redeeming  feature 
upon  which  to  ground  his  re-educative  suggestions. 

Re  vomiting,  Roussy  and  Lhermitte  state  that  this  rela- 
tively common  condition  is  diagnosticated  readily  enough 
but  that  pyloric  ulcer  and  other  organic  causes  must  be 
eliminated.  They  remark  that  there  is  no  tendency  to  spon- 
taneous cure  of  neuropathic  vomiting,  and  commend  strict 
dietetic  regime  and  psychotherapy.  They  ally  the  condi- 
tion in  its  nature  and  genesis  with  so-called  false  or  hysteri- 
cal incontinence  of  urine  in  soldiers.  Wiltshire's  case  early 
received  the  diagnosis  "gastritis."  It 'is  remarkable  how 
little  emaciation  need  follow  such  vomiting. 


shell-shock:  nature  and  causes  477 


Shell-shock :  Amnesia ;  dreams  of  falling.  POST- 
ONIRIC  suggestion  —  surprise  produced  fear  of 
falling. 


Case  346.     (DuPRAT,  October,  191 7.) 

A  man  was  subjected  to  shell-shock  August  11,  1916,  at  the 
Somme.  He  lost  consciousness  for  five  hours  and  was  picked 
up  stuporous  with  verbal  amnesia,  which  soon  passed  leaving 
only  a  difficulty  in  getting  the  right  word  promptly.  He 
began  to  have  frightful  dreams  of  falling  into  a  hole  and  of 
exertions  to  avoid  falling,  whereupon  he  would  awake  with 
a  feeling  of  anxiety  that  would  last  some  time.  Treatment 
caused  the  dreams  to  disappear. 

There  remained,  however,  a  powerful  post-oniric  suggestion. 
Any  slight  surprise  would  cause  the  fear  of  falling  to  reappear. 
There  was  a  sort  of  derived  phobia,  against  any  military  act 
that  would  need  to  be  performed  upon  sudden  order.  He 
developed  a  blind  anger  against  any  commanding  officer  who 
gave  a  brusque  order.  After  the  crisis  of  anger  he  would  fall 
into  tears  and  a  feeling  of  profound  depression  coupled  with 
precordial  anxiety.  There  was  also  a  chronic  aortitis  physi- 
cally determined.  The  man  himself  had  a  vague  idea  of  the 
relationship  of  his  fear  of  surprise  to  the  old  nightmares. 

Re  persistence  of  fear  and  its  relationship  to  nightmares, 
see  remarks  under  Case  342  (Rows). 


478  shell-shock:  nature  and  causes 


Four  months'  SERVICE  IN  THE  REAR :  Depres- 
sion; war  HALLUCINATIONS  (not  based  upon 
actual  experiences) ;  psychasthenic  symptoms. 


Case  347.     (Gerver,  1915.) 

A  Russian  lieutenant,  32,  arrived  at  the  front  in  November, 
1914,  but  never  served  on  the  front  line,  or  had  occasion  to 
visit  the  line  or  the  trenches.  Toward  the  close  of  February, 
mental  symptoms  appeared,  which  caused  the  man's  evacua- 
tion to  the  interior. 

He  was  a  tall,  well-built,  well-nourished  man,  who  was 
physically  normal  except  for  sharp  twitching  movements 
of  the  tongue,  eyelids,  and  face;  tremors  of  extended  hands, 
occasionally  spreading  to  the  whole  body;  well-defined  der- 
matographia  (in  places,  stereodermatographia) ;  exaggerated 
tendon  reflexes ;  tenderness  of  skull  and  spine ;  hyperesthesia 
of  chest;   pulse  120. 

Mentally,  the  patient  was  markedly  depressed,  irritable, 
at  times  lacrimose.  His  complaints  were  of  a  psychasthenic 
tinge.  He  feared  incurable  disease.  He  feared  to  go  to  the 
front,  and  was  terrified  at  what  he  might  do  there.  He  feared 
crowds  of  soldiers;  he  was  afraid  of  forests  and  mountains; 
the  Germans  were  going  to  break  through  and  capture  him; 
shells  were  about  to  burst  over  his  head.  He  was  also  dis- 
turbed about  his  family,  regarding  his  wife  and  son  as  helpless, 
sometimes  even  as  dead.     Suicidal  thoughts  at  times. 

At  night,  though  he  had  never  been  at  the  front,  he  had 
hallucinations  of  shots  and  the  voices  of  soldiers,  as  well  as 
those  of  his  wife  and  son.  He  smelt  an  unpleasant  corpse- 
like odor.  He  was  unable  to  distinguish  these  hallucinations 
in  any  respect  from  reality.  He  complained  of  general 
weakness,  headaches,  palpitation  of  the  heart,  vertigo,  and 
insomnia,  and  of  a  variety  of  pains. 

He  was  non-alcoholic  and  non-syphilitic,  and  had  been  in 
perfect  health  before  the  war. 

Re  war  hallucinations  with  service  back  of  the  line,  com- 
pare remarks  of  Regis  (see  under  Case  333). 


SHELL-SHOCK:    NATURE  AND   CAUSES  479 


A  case  of  hysterical  astasia-abasia  develops  '*big 
belly"  ("catiemophrenosis"),  perhaps  by  hetero- 
suggestion  from  a  ward  neighbor. 


Case  348.     (RoussY,  Boisseau  and  Cornil,  May,  191 7.) 
A  farmer,  22,  of  the  foot  chasseurs,  who  had  been  in  various 
hospitals  \\ith  a  variety  of  diseases  before  his  injury,  was 
evacuated  June  2,  1916,  for  "contusion  of  back,"  to  the  tem- 
porary hospital  at  Bussant,  from  which  he  was  evacuated  to 
Pontarlier  for  "contusion  of  back  and  cerebellar  shock  "  and 
thence,  July  21,  to  Besangon  for  "internal  contusion  and  cere- 
bellar shock";  thence  to  four  other  hospitals  from  July  31  to 
February  17,  1917;   finally  to  the  Hospital  at  V'eilpicard  with 
"functional  disorders,  paraplegia,  trepidant  astasia-abasia." 
It  seems  that  he  had  lost  consciousness  for  fifteen  days  and 
had  thereafter  been  paraplegic  with  retention  of  urine.     The 
abdomen  had  then  increased  in  size  in  such  wise  as  to  be 
termed  a  nervous  pregnancy,  grosses se  nerveuse.    The  evolution 
of  this  pseudotympanites  was  probably  related  to  the  presence 
of  the  same  so-called  "big  belly  "  of  a  patient  who  had  been 
in  a  neighboring  bed  from  May,  1916,  onwards.     The  feet  were 
in  equine  position  with  toes  flexed,  suggestive  in  all  ways  of 
hysterical  paraplegia.     The  abdomen  looked  like  that  of  a 
woman  six  months  pregnant  and  measured  78  centimeters  in 
a  plane  passing  through  the  anterosuperior  iliac  spines  and 
the]  umbilicus.     The  abdomen  was  hard,  tense,  swollen,  and 
on  palpation,  gave  out  a  low,  tympanic  note.      When  the 
diaphragm  was  mobilized  progressively  and  slowly,  the  tym- 
panites could  be  made  to  disappear.     Slow  pressure  on  the 
abdomen  with  fiat  hands  effaced  the  swelling  for  the  time 
being;  but  upon  release  of  the  hands  the  abdomen  would  swell 
up  again  as  before.     Pressure  on  the  abdomen  produced  a 
contracture  of  the  recti.     Forced  flexion  of  thighs  on  pelvis 
(as  suggested  by  Denechau  and  Matrais)   also  caused  the 
swelling  to  go  down.     Faradization  of  the  phrenic  nerves  in 
the  neck  caused  respiratory  movements  with  a  slight  diminu- 
tion in  the  volume  of  the  abdomen.     There  was  an  obstinate 


480  SHELL-SHOCK:    NATURE  AND  CAUSES 

constipation  requiring  daily  lavage.  Respiratory  movements 
were  short  and  rapid  and  of  the  thoracic  type.  Abdominal 
compression  caused  the  respiration  to  assume  almost  a  normal 
rhythm.  X-ray  examination  of  the  abdomen,  after  50  grams 
of  bismuth  carbonate  had  been  taken  in  three  spaced  doses 
the  evening  before,  showed  the  intestine  to  be  distended  by 
gas  in  such  wise  that  the  lower  border  of  the  liver  became 
clearly  visible,  as  after  insufflation  of  the  stomach.  The  bis- 
muth was  found  in  the  large  intestine.  The  splenic  angle 
filled  with  bismuth  was  low.  On  compression  the  splenic 
angle  was  raised  with  the  diaphragm. 

The  main  features  of  this  disease  are  the  large  abdomen, 
simulating  what  has  hitherto  been  found  chiefly  in  females 
under  the  name  of j  nervous  pregnancy,  but  also  suggesting  a 
tuberculous  peritonitis  (one  patient  was  actually  evacuated 
to  a  hospital  for  tuberculosis  with  this  disease) ;  gastrointes- 
tinal disorder  with  aerophagy,  aerocoly,  and  obstinate  con- 
stipation (one  case  also  showed  almost  daily  vomiting).  The 
genesis  of  the  condition  appears  to  be  a  contracture  of  the 
diaphragm  in  a  low  position  of  forced  inspiration.  The  con- 
dition may  be  termed  a  diaphragmatic  neurosis. 

Psychotherapy  was  applied,  the  patient  was  requested  to 
walk,  and  the  movements  made  in  walking  required  such  an 
intense  respiration  that  the  diaphragm  was  forced  to  function, 
whereupon  the  "big  belly"  disappeared.  The  digestive  dis- 
orders then  rapidly  disappeared.  These  authors  suggest  the 
name  of  catiemophrenosis. 


SHELL-SHOCK:     NATURE   AND   CAUSES  48 1 


War  stress ;  collapse  going  over  the  top :    Neuras- 
thenia (hereditary  taint ;  alcoholism) . 


Case  349.     (Jolly,  January,  191 6.) 

A  German  soldier,  35,  of  a  nervous  make-up  (his  mother 
was  nervous,  and  he  had  been  nerv^ous  and  tremulous  and 
easily  excitable,  and  alcoholic  to  the  extent  of  at  least  5 
glasses  of  beer  every  night),  was  called  to  the  colors  in  Sep- 
tember, 1914.  He  got  through  his  training  well;  in  May, 
1 91 5,  was  on  very  strenuous  duty  in  a  very  exposed  position, 
had  frequently  to  stand  up  under  hea\^  shelling,  had  a  num- 
ber of  frightful  experiences,  was  surrounded  by  corpses  and 
mutilated  bodies,  and  frequently  took  part  in  storming  attacks. 
His  ner\"ousness  came  to  a  head  with  some  suddenness;  just 
as  he  was  about  to  "go  over  the  top,"  he  had  no  strength  for 
the  effort  and  collapsed.  Thereafter  he  could  no  longer 
stand  shelling,  could  not  speak,  and  was  inattentive  to  sur- 
roundings. When  he  was  examined  by  a  physician  he  fell 
asleep  in  his  presence,  although  sleep  had  latterly  been  al- 
most impossible  on  account  of  the  shelling.  He  was  im- 
mediately put  on  the  hospital  train  and  taken  to  the  reserve 
hospital  in  Nuremberg,  where  he  presented  an  appearance  of 
extreme  exhaustion,  wept,  seemed  much  fatigued,  and  trem- 
bled all  over  whenever  he  started  to  do  anything.  He  was 
very  easily  excited  and  especially  sensitive  to  noise.  There 
was  a  fine  tremor  of  the  whole  body  and  especially  of  the 
head;  the  knee-jerks  were  increased;  there  was  a  moderate 
vasomotor  reddening  of  the  skin  after  stroking;  his  tongue 
was  heavily  coated ;  but  there  was  no  other  evidence  of  inter- 
nal disorder.     His  pulse  was  strong  and  not  rapid. 

The  patient  got  well  gradually,  complained  at  first  of  bad 
dreams,  and  was  given  to  weeping.  The  tremors  slowly 
improved.     The  patient  grew  better  in  a  hospital  at  home. 

As  to  the  diagnosis  of  this  case,  Jolly  regards  it  as  one  of 
nervous  exhaustion.  The  remarkable  feature  is  the  tardiness 
with  which  the  symptoms  developed  under  the  stress  of  war. 
Such   a  patient  would   probably  never  develop   a   neuras- 


482  SHELL-SHOCK:    NATURE  AND   CAUSES 

thenia  under  normal  peace  conditions.  After  recovery  these 
patients  may  be  sent  back  for  garrison  duty  or  for  other 
work  not  directly  connected  with  the  firing  line.  As  for  the 
tendency  to  desire  a  pension,  this  wish,  according  to  Jolly, 
must  be  strenuously  opposed,  both  in  the  interest  of  the 
state  and  that  of  the  patient.  If  there  is  no  will  to  get  well, 
some  of  these  patients  are  found  vibrating  from  garrison 
service  to  furlough  and  to  hospital. 

The  above  case  is  one  of  the  simplest  observed ;  yet  there 
is  evidence  both  of  hereditary  taint  and  of  alcoholism.  Ac- 
cording to  Jolly,  the  majority  of  the  severe  exhaustion  states 
of  a  neurasthenic  nature  have  been,  in  his  experience,  dis- 
tinctly nervous  before  the  war,  and  frequently  show  heredi- 
tary taint  as  well. 

Re  neurasthenia,  see  views  of  Babinski  relative  to  differ- 
entiation from  hysteria  (under  Case  340). 


SHELL-SHOCK:  NATURE  AND  CAUSES        483 


Series  of  battles :  Sudden  mania  followed  by  con- 
fusion with  fixation  of  mind  upon  war  experiences, 
possibly  hallucinatory;  general  analgesia. 


Case  350.     (Gerver,  191 5.) 

A  Russian  private,  looking  much  older  than  his  years  (35), 
had  been  in  a  number  of  battles  without  mental  disorder. 
Where  he  was  posted,  however,  there  was  a  heavy  artillery 
fire  in  the  last  of  the  battles.  Suddenly  the  man  became 
excited  and  leaped  upon  his  comrades'  shoulders  crying, 
"The  devil  is  here!  This  is  hell  and  murder,  and  here  are  the 
devil's  imps!  "  The  commanding  officer  accordingly  ordered 
him  to  the  rear.  His  regiment  had  suffered  severe  losses  in 
a  succession  of  attacks  upon  a  certain  strategic  height. 

Upon  evacuation  to  the  field  hospital  and  thence  to  the 
interior,  his  excitement  did  not  lessen,  i  He  went  about  with 
a  lost  look,  trembling,  talking  a  great  deal  and  gesticulating. 
His  talk  was  incoherent  and  pointless.  After  every  few 
phrases,  he  would  repeat,  "Don't  ride  there!  That's  hell! 
Murder  is  being  done.  Devils  and  unholy  powers  are  beat- 
ing and  killing  people."  As  he  said  this,  he  would  tremble, 
and  hands  and  feet  would  stiffen  with  a  suggestion  of  cata- 
lepsy. There  was  general  anesthesia  to  pain;  no  response 
was  made  to  deep  pin-pricks.  The  pupils  were  dilated  and 
failed  to  react,  either  to  light  or  to  pain.  The  tendon  reflexes 
were  exaggerated.  No  contraction  of  visual  fields.  The  man 
was  disoriented  for  time  and  place  and  much  confused.  No 
paralysis.     No  wound  or  contusion. 

Re  analgesia,  we  may  only  say  that  hysterical  anesthesia 
appears  in  a  variety  of  forms;  sometimes  (a)  in  the  form  of 
a  classical  stigma  of  hemi-anesthesia ;  (b)  in  a  segmentary 
form;  again  (c)  in  isolated  patches;  (d)  in  a  very  rough 
way  approximating  the  peripheral  nerve  distributions.  Ba- 
binski  gives  an  unpublished  note  by  Lasegue,  in  which  he 
states  that  hysterical  patients  not  enlightened  by  the  doc- 
tor's investigations  do  not  make  mention  of  anesthesia.  But 
in  case  350  a  psychotic  factor  may  have  entered. 


484  SHELL-SHOCK:    NATURE   AND   CAUSES 


Ten  months  of  military  service  (several  battles) 
without  reaction ;  then,  hot  machine  gim  battle : 
Mania  with  disorientation  and  war  hallucinations. 


Case  351.     (Gerver,  1915.) 

A  Russian  private,  24,  in  a  scout  company,  entered  the 
war  on  mobilization  and  took  part  in  several  battles  without 
reaction.  May  11,  191 5,  he  was  sent  with  the  scout  party 
into  a  hot  encounter,  hand  to  hand  with  machine-guns. 
After  the  battle,  the  man  began  to  yell  incoherent  phrases  at 
the  men  around  him,  started  to  climb  over  the  top,  and  shot 
off  his  gun  without  permission.  He  was  accordingly  sent  to 
hospital,  where  he  was  under  observation  for  a  week,  during 
which  he  had  occasional  flashes  of  excitement,  jumping  out 
of  bed  and  making  movements  of  cutting  or  shooting,  and 
then  in  a  few  minutes  subsiding  Into  Inactivity. 

He  was  a  short  but  well-built  and  well-nourished  man; 
the  pupils  responded  rather  weakly  In  accommodation ;  there 
was  a  small  fibrillar  tremor  of  the  face,  eyes,  and  tongue. 
The  skin  reflexes  were  diminished  and  there  was  a  general 
hypalgesia;  considerable  mechanical  overexcitablllty  of  mus- 
cles; no  other  neurological  disorders.  The  mental  state  was 
one  of  confusion.  Although  he  was  In  one  of  the  corps  hos- 
pitals, he  said  he  was  in  a  dug-out ;  the  doctors  were  lieuten- 
ants; the  attendants  were  privates  In  his  company.  Answers 
to  questions  were  irrelevant  or  Incoherent;  there  were  a 
number  of  delusional  expressions.  He  was  to  be  shot  be- 
cause he  had  not  himself  shot  enough  Germans.  If  he  were 
not  to  be  shot,  anyhow  the  soldiers  would  poison  him. 
Rather  than  this  he  should  be  allowed  to  go  Into  an  attack. 
He^would  take  a  German  fort  and  the  Czar  would  name  him 
a  colonel.  His  regimental  commander  was  saying  to  him, 
"You  will  be  a  hero,  you  will  soon  get  a  company."  His 
hallucinations  sometimes  Included  the  voices  of  Germans 
saying,  In  broken  Russian,  "We  will  hang  you  and  cut  your 
belly  open  ! "  There  was  considerable  amnesia  for  dates 
and  even  his  last  battle. 


SHELL-SHOCK:    NATURE   AND   CAUSES  485 


Numerous  attacks  and  counter  attacks  in  one  day : 
Sudden  incoherence  with  disorientation  and  the 
rapid  development  of  war  hallucinations  of  a  scenic 
type.     Suggestion  of  catatonic  phenomena. 


Case  352.     (Gerver,  1915.) 

A  Russian  lieutenant,  28  (no  mental  disease,  non-al- 
coholic), was  in  battle  August  14,  1914,  on  which  day  his 
company  attacked  and  was  itself  attacked  several  times.  An 
officer  who  observed  the  lieutenant  said  that  he  came  to  him 
and  informed  him  that  the  Germans  must  first  be  burned  and 
then  fought  with.  Thereafter  the  lieutenant  began  to  speak 
loudly  and  incoherently,  sometimes  yelling  incoherent  orders. 
He  was  accordingly  removed  from  the  battle-field  to  the  hos- 
pital back  of  the  line.  Upon  examination,  he  was  found  to 
be  of  middle  height,  with  dilated  pupils,  responding  weakly 
to  light  and  not  at  all  to  accommodation ;  twitchings  of  face, 
eyelids,  and  tongue,  digital  tremor,  marked  dermatographia, 
general  analgesia,  tendon  reflexes  somewhat  exaggerated, 
cataleptic  tendency  in  feet  and  hands. 

Mentally,  the  patient  was  in  a  stupor,  sitting  or  standing 
in  one  place,  without  initiative ;  uncomplaining  but  occasion- 
ally uttering  deep  sighs  or  occasional  isolated  phrases.  He 
answered  no  questions  or  only  after  a  long  pause.  He  was 
disoriented  for  time  and  place,  but  gave  evidence  of  delu- 
sions and  hallucinations.  He  thought,  for  example,  that  he 
was  the  chief  of  staff  and  had  brought  with  him  a  squad  of 
captured  Germans  who  were  standing  nearby.  Some  wanted 
to  be  fed  and  let  go;  others  were  yelling  and  saying  they 
would  burn  down  the  house.  Sometimes  the  patient  would 
hear  shots  and  shells  bursting,  at  which  he  would  shudder 
and  turn  away.  Apparently  he  would  see  his  comrades  fall- 
ing under  the  shrapnel  hail.  However,  he  stood  his  ground 
and  commanded  the  rest  of  the  soldiers  to  go  forward  to  the 
attack.  Now  and  then  he  was  negativistic,  flexing  the  hands 
upon  request  to  extend  them,  refusing  food  and  drink.  He 
was  still  apathetic  on  evacuation  to  the  interior. 


486  shell-shock:   nature  and  causes 


Shell-shock  after  two  days  in  trenches:  Hysteri- 
cal STUPOR  seven  days.  Cure  in  three  weeks, 
barring  amnesia  for  stuporous  period. 


Case  353.     (Gaupp,  March,  1915.) 

F.  S.,  in  civil  life  a  wreath-binder  in  a  flower  shop,  and 
from  childhood  very  nervous  and  excited,  subject  to  frequent 
nosebleeds  and  fainting  spells  {e.g.,  at  sight  of  blood),  en- 
listed at  22,  November  3,  1914,  as  a  reservist.  January  18 
he  went  into  the  field. 

The  wreath-binder  was  only  two  days  in  the  trenches 
before  going  unconscious  under  the  whistling  and  exploding 
shells.  Physically  uninjured,  he  was  received  in  reserve 
hospital  C  in  a  deep  stupor,  January  22.  He  was  unre- 
sponsive at  first,  once  however  saying,  lost  in  a  dream,  "When 
will  mother  come?  "  His  gait  was  unsteady  and  he  had  to 
be  led  and  held.     He  slept  a  good  deal  in  the  daytime. 

He  became  somewhat  more  active  mentally,  January  24 
(remarking  that  he  had  slept  well),  and  made  his  toilet,  but 
he  did  not  yet  have  bearings  and  wanted  to  go  to  his  place  of 
business.  The  next  day  his  condition  was  similar.  Asked 
what  troop  he  was  with,  he  said,  "In  the  flower  business." 
January  26  he  was  much  better,  telling  of  the  army  training 
and  a  little  about  the  war,  and  wrote  a  postcard  to  his  par- 
ents. The  stupor  disappeared  after  January  27  and  the 
patient  became  mentally  normal.  Amnesia  persisted  for  the 
time,  January  20  to  26.  Headaches.  February  9  he  was 
well,  except  for  the  [limited  amnesia  still  persisting.  He  was 
eventually  sent  back  to  garrison  duty,  cured. 

Re  stupor,  Grandclaude  remarks  that  stupor  is  probably 
the  most  frequent  of  the  mental  symptoms  of  Shell-shock, 
and  that  it  may  last  from  a  few  moments  to  a  week.  During 
the  stupor  the  patient  is  asthenic,  stertorous,  and  staring. 
Upon  recovery  from  the  stupor,  a  condition  of  dulness  with 
amnesia  and  disorientation  ensues.  There  may  be  a  third 
phase  of  a  more  hyperkinetic  character,  with  hallucinations 
and  delusions  concerning  the  war.     These  stuporous  cases 


shell-shock:  nature  and  causes  487 

are  among  the  most  serious  of  the  conditions  found,  as  some 
of  the  victims  may  even  suggest  dementia  praecox  from  the 
persistence  of  childishness  and  silliness.  As  in  Gaupp's  case, 
Grandclaude  finds  that  headaches  and  amnesia  persist.  Re- 
lapses are  frequent  on  the  basis  of  a  kind  of  sensitization. 

Re  amnesia  and  Shell-shock,  Roussy  and  Lhermitte  speak  of 
amnesia  as  ordinarily  a  phenomenon  of  confusion.  Amongst 
the  mental  disorders  of  the  Shell-shock  psychoses,  these 
authors  describe  a  group  due  to  inhibition  or  diminution  of 
mental  activity,  including  the  rare  narcolepsy,  or  pathologi- 
cal sleep,  and  the  confusional  states  proper.  Simple  con- 
fusion involves  slowness  in  thinking,  and  amnesia  often 
anterograde  from  the  moment  of  the  shock.  Simple  con- 
fusion ought  to  be  distinguished  from  so-called  "obtusion" 
or  torpor,  in  which  there  is  a  disorientation  for  time  and  space, 
such  as  was  shown  in  Mallet's  case.  Chavigny  has  described 
an  aprosexic  form  (with  "birdlike"  movements).  ■  More  com- 
mon is  the  amnestic  form  of  torpor.  The  amnesia  may  not 
merely  be  anterograde  from  the  moment  of  shock,  but  may 
extend  to  a  prolonged  period  prior  to  the  accident.  Some- 
times the  amnesias  are  selective,  producing  phenomena  of 
pseudo  aphasia. 


488  shell-shock:   nature  and  causes 


Amnesia,       mono  symptomatic.        Progressive    re- 
covery. 


Case  354.     (Mallet,  January,  191 7.) 

An  infantryman,  36,  arrived  without  information  at  a 
psychiatric  center,  March  15,  1916,  looking  confused  and 
knowing  Httle  more  than  his  name,  beHeving  himself  in  a 
distant  town.  The  disorientation  lasted  to  March  21,  on 
which  day  the  man  recognized  the  doctor  as  such,  knew  that 
he  was  at  a  hospital,  but  felt  that  he  had  just  left  home  and 
wife.  From  this  time  on,  he  began  to  pick  up  his  surround- 
ings, evidently  not  knowing  that  there  was  a  war  or  that  he 
was  a  soldier.  He  did  not  recognize  one  of  his  own  com- 
pany. It  was  not  until  March  31  that  the  first  memory  of 
the  war  reappeared,  namely,  a  memory  of  the  call  to  the 
colors,  drums,  bells,  and  crowds.  April  11  he  recollected 
that  he  was  a  soldier  and  that  his  wife  was  in  the  country, 
where  he  had  left  her  on  the  eleventh  day  of  the  mobilization. 
In  the  next  few  days,  memories  came  back  bit  by  bit.  He 
had  been  at  first  a  little  thin  and  showed  a  slight  fever, 
oliguria,  and  poor  digestion.  All  these  symptoms  now 
lapsed,  and  the  man  became  apparently  perfectly  well. 

Such  states,  according  to  Mallet,  are  relatively  frequent 
in  soldiers,  both  in  epilepsy,  and  in  Infectious  deliria,  — 
more  than  in  the  deliria  of  exhaustion. 


SHELL-SHOCK:    NATURE   AND   CAUSES  489 


Aviator  shot  down :  Organic  mental  symptoms. 


Case  355.     (MacCurdy,  July,  1917.) 

A  Canadian,  20,  of  normal  makeup,  in  191 5  lost  part  of 
his  left  foot  in  a  railway  accident,  but,  notwithstanding,  was 
finally  commissioned  in  the  Royal  Flying  Corps.  He  en- 
joyed the  nine  months  of  English  training  greatly.  In 
France  he  made  several  successful  flights  over  the  lines,  but 
was  shot  down  and  crashed  to  the  ground  within  the  British 
lines  after  two  weeks  of  service.  He  got  black  eyes  and 
bruises  and  lost  consciousness  for  about  four  days,  though  a 
week  later  he  was  still  hazy  about  recent  events  and  was  not 
quite  sure  in  what  hospital  he  lay.  After  another  week  he 
arrived  in  a  London  hospital. 

Here  he  would  not  answer  questions,  but  stared  at  the 
examiner,  finally  shouting:  "I  want  to  get  up."  He  said  he 
was  in  a  certain  suburb  of  Toronto,  which,  however,  he  in- 
sisted was  a  part  of  London  not  far  away.  He  wanted  a 
taxicab  to  go  thither.  He  pondered,  but  seemed  content 
when  told  that  Rosedale  was  across  the  ocean.  A  super- 
ficial machine  gun  wound  of  the  hip  the  patient  said  must  be 
the  mark  of  a  hospital  in  France  it  was  a  secret  mark, 
meaning  that  he  could  return  to  the  line  and  fight  whenever 
he  wanted  to  and  that  he  could  use  the  lavatory  whenever 
he  wanted  to.  He  sometimes  uttered  brief  phrases  after 
questioning.  Asked  if  he  dreamed,  he  looked  up  cunningly 
and  said,  e.g.,  "  I  down  the  Boche.     I  am  a  live  wire." 

Next  day  it  was  clear  that  he  had  gained  a  good  deal  of 
information  from  the  nurses,  and  the  day  after  he  had  be- 
come oriented  for  time  and  able  to  recognize  the  physician, 
though  still  confused  about  hospital  names  and  his  recent 
movements.  The  7  from  100  test  he  did  slowly  and  made 
several  bad  unrecognized  mistakes.  He  was  over-fatigue- 
able,  complained  of  foggy  eyesight,  showed  haziness  and  red- 
ness and  obscure  margins  in  the  optic  discs,  with  the  remains 
of  one  hemorrhage,  and  presented  nystagmus  on  looking  to 
the  extreme  left.  Two  weeks  later  he  complained  less  of  his 
memory  and  said  that  he  was  beginning  to  remember  what 


490  SHELL-SHOCK:    NATURE  AND  CAUSES 

had  happened  during  the  last  day  of  his  fighting;  the  chase 
by  the  German  airplane  and  the  maneuvers.  He  worried 
about  being  sent  back  to  France  by  a  medical  board,  which 
would  not  realize  that  he  was  incompetent  to  fly  again.  The 
left  pupil  was  slightly  larger  than  the  right. 

In  this  case  there  were  no  neurotic  symptoms  and  accord- 
ing to  MacCurdy  the  difficulties  here  are  strictly  those  of 
organic  type. 

Re  organic  cases  of  traumatic  psychosis,  Lepine  sums  up 
the  subjective  phenomena  as  follows:  There  is  (a)  a  cephalea, 
often  a  feeling  of  weight,  varying  at  different  times  of  the  day ; 
often  frontal;  often  subject  to  marked  alteration  on  move- 
ment. There  may  be  {h)  a  number  of  visual  phenomena  like 
those  mentioned  under  Case  355,  part  and  parcel  of  a  sort 
of  absence,  suggesting  an  epileptoid  effect.  Sometimes  (c) 
there  is  vertigo,  but  this  is  rare.  There  are  also  congestive 
attacks.  The  patients  are  unable  to  work,  and  have  strange 
head  sensations  when  they  attempt  to  work.  The  memory 
disorder  is  not  as  a  rule  markedly  accentuated.  This  am- 
nesia is  usually  a  disordered  fixation  of  current  events,  but 
there  is  also  a  retrograde  amnesia.  Insomnia  and  impulsive- 
ness are  also  found,  and  more  rarely  is  a  depressed  and 
melancholy  state  suggesting  that  which  Case  355  exhibited. 
Lepine  has  tried  to  define  the  traumatic  psychoses  (not 
neuroses)  on  the  basis  of  phenomena  found  in  trephined 
cases.  He  remarks  upon  the  extreme  analogy,  not  to  say 
identity,  between  the  late  sequelae  of  trephining  and  the 
syndrome  of  commotio  cerebri. 


SHELL-SHOCK:    NATURE   AND   CAUSES  49 1 


Daze  with  relapses ;   mutism  —  following  shell  fire 
and  corpse  work. 


Case  356.     (Mann,  June,  191 5.) 

A  soldier  lost  his  voice  apparently  from  two  factors:  shell 
fire  and  the  emotional  shock  of  helping  to  fill  the  big  common 
graves.  The  man  could  never  tell  for  certain  (retrograde 
amnesia)  whether  he  went  from  corpses  to  shell  fire  or  from 
shell  fire  to  corpses. 

Several  weeks  of  daze  followed  in  which  he  hardly  reacted 
to  outward  stimuli,  but  occasionally  said  "It  smells!" 
"Leave  me  still!" 

He  recovered  gradually  from  the  daze.  But  merely  hinting 
at  his  experiences,  especially  the  smells,  sufficed  to  throw 
him  into  another  daze. 

The  loss  of  voice  lasted  for  some  time  after  he  had  wholly 
stopped  lapsing  into  the  dazed  states. 

There  was  some  alcohol  in  the  previous  history  of  this 
case,  which  is  the  only  case  among  twenty-three  Shell-shock 
cases  reported  by  Mann  which  had  a  psychiatric  disorder  of 
any  lasting  nature  due  to  shell  fire. 

Re  mutism  and  the  two  factors  of  shell  fire  and  emotion 
spoken  of  by  Mann,  compare  the  views  "of  Babinski  to  the 
effect  that  emotion  alone  is  unable  to  cause  such  a  hysterical 
manifestation  as  mutism 

Re  the  corpse  work,  see  remarks  under  Case  342. 


492  SHELL-SHOCK:    NATURE   AND   CAUSES 


Mine    explosion:        Mental    confusion.     Amnesia 
effected  through  Y.  M.  C.  A. 


Case  357.     (Wiltshire,  June,  191 6.) 

A  sapper,  21,  was  admitted  to  a  base  hospital  semi-stupor- 
ous,  unable  to  answer  questions  and  mistaking  the  identity 
of  persons  about  him.  At  first  he  slept,  but  next  day  found 
he  was  in  hospital.  His  mind  was  "all  of  a  blur."  He  did 
not  remember  coming  to  France;  "  It  all  seems  a  mist."  He 
felt  he  was  ill  and  was  afraid  of  becoming  insane.  There  was 
no  physical  sign  of  disease  except  coarse  tremor  of  hands. 

At  intervals  over  a  period  of  about  half  an  hour,  helped 
by  questions,  he  was  able  to  get  out  the  following  with 
much  emotion: 

"Joe,  don't  go  —  Give  me  my  rifle,  Joe  —  Ten  killed. 
Poor  old  Taffy  —  Dreamed  last  night  —  Saw  Harry 
Edmands  with  all  his  ribs  broken  —  when  we  had  the 
explosion  —  5000  bombs  or  two  and  a  half  tons  of  ex- 
plosives blew  up.  —  Joe  —  Clay  said  he  would  never 
live  three  weeks,  —  Glasses  blown  in.  —  Taffy  killed 
by  shell  in  stomach  —  S  —  L  —  All  privates  blown 
off  him  —  Just  after  leaving  workshop." 

Between  the  above  statements,  the  patient  might  go  off 
into  short  trance  states,  staring  and  pointing  out  of  the  tent. 

Next  day  he  was  found  in  a  condition  of  cheerful  emotion, 
saying  that  he  was  ever  so  much  better;  an  orderly  had 
"saved  him! "  This  orderly  had  taken  him  to  the  Y.  M.  C. 
A.  recreation  tent,  played  the  piano  to  him,  and  made  him 
play  himself.  His  whole  emotional  state  suddenly  changed 
over.  He  now  had  a  good  memory  for  everything  previous 
to  his  reaching  France,  and  remembered  simply  that  there 
had  been  an  explosion.  He  remembered  two  names  that  he 
had  mentioned,  but  he  co-uld  remember  nothing  about  their 
fate  in  France.  He  did  not  know  where  they  were  but  he 
was  not  anxious  about  them. 


SHELL-SHOCK:    NATURE   AND    CAUSES  493 


Shell-shock:    Hallucmations ;   alternations  of  per- 
sonality. 


Case  358.     (Gaupp,  March,  1915.) 

A  soldier,  29,  a  helper  in  a  wholesale  house,  came  to  a 
hospital  by  hospital  train,  uninjured,  directly  from  the  field, 
having  become  completely  deranged  under  shell  fire.  He 
arrived  at  the  clinic  January  11,  1915,  in  deep  emotion, 
anxiously  excited,  and  looking  tensely  and  suspiciously  at  the 
bystanders.  He  seemed  to  hear  very  badly  and  shouted  his 
statements  like  a  deaf  person.  Led  to  the  sick  section,  he 
shouted  out  of  the  window,  "Frenchmen!";  then  he  went 
willingly  to  the  bath  and  was  put  to  bed,  unresisting.  He 
lay  in  bed  on  his  elbow,  listening  in  the  direction  of  the 
window  or  the  wall,  answering  loud  questions  with  a  quick, 
yelling  voice  after  a  pause.  He  gave  his  name  correctly. 
He  seemed  to  think  he  was  in  the  trenches  and  to  see  hal- 
lucinatory pictures  of  battle. 

In  the  examining  room  he  immediately  sat  down,  back 
to  the  wall,  taking  the  chair  at  the  desk  and  leaning  it  against 
the  wall.  Asked  why  he  did  so,  he  said  with  a  horrified  ex- 
pression, "The  shells,  they  are  coming  over!  Whew!  they 
are  shooting  all  the  time."  He  ducked,  imitating  the  hissing 
and  whistling  of  the  shells.  Asked  if  he  had  been  struck,  he 
said,  "There  are  two  dead  and  one's  head  is  off."  He  de- 
clined to  be  told  where  he  was,  and  when  he  was  told  that  he 
was  no  longer  in  the  enemy's  country,  but  in  Wiirttemberg, 
he  said,  "No,  no;  they  don't  come  so  far.  No,  the  French- 
men don't  come  so  far."  He  was  very  easily  frightened  and 
started  at  every  touch  as  if  wakened  from  a  dream.  Some- 
times his  whole  body  would  tremble  with  anxiety.  He 
would  not  allow  his  pulse  to  be  taken,  at  first.  He  would 
suddenly  shout,  "That's  the  Krupp  now  flying  by.  Now  it 
has  struck."  He  cast  his  eyes  along  the  ceiling  as  if  to  follow 
the  course  of  the  shell.  Asked  what  he  was  doing,  he  said  he 
was  in  the  trench  on  the  mountain. 

He  was  able  to  tell  about  his  family,  his  marriage  in  Berlin, 


494  SHELL-SHOCK:    NATURE  AND  CAUSES 

and  his  child,  and  he  could  tell  time  by  the  clock.  Then  he 
would  suddenly  shout:  "The  shells,  they  are  shooting  every- 
thing; they  are  shooting  like  another  earthquake."  Gaupp 
stepped  up  to  him,  in  uniform,  and  asked  if  the  patient  knew 
him.  He  examined  Gaupp  suspiciously  from  top  to  toe, 
looked  at  the  shoulder-straps,  and  then  quickly  cried  loudly, 
"Physician." 

At  ajnother  time  he  described  the  shell  havoc  with  evidence 
of  extreme  anxiety.  He  would  take  food  only  when  one 
broke  off  a  piece  and  ate  of  it  before  him.  He  would  not 
drink  out  of  ordinary  drinking-glasses  but  only  out  of  his 
field  cup,  examining  it  carefully.  He  denied  he  was  on  patrol 
duty  at  Soupis.  His  comrade  was  merely  asleep  just  now. 
A  civilian  physician  in  his  long  coat  was  termed  by  the 
patient  "a  baker  "  after  careful  examination.  There  seemed 
to  be  no  pause  in  the  man's  behavior,  which  looked  abso- 
lutely genuine  and  dominated  by  strong  emotion.  He  had 
the  look  of  a  man  in  immediate  danger  of  death,  exerting 
himself  to  escape  shell  fire. 

This  dream-like  disorder  of  consciousness  with  war  de- 
lirium persisted  for  a  number  of  days.  There  was  no  marked 
motor  excitement.  He  would  remain  for  the  most  part 
quietly  in  bed,  absorbed  in  his  thoughts,  watching  and  listen- 
ing, sometimes  looking  about  in  astonishment  but  not  getting 
his  bearings.  Gradually  his  emotions  declined  and  he  de- 
veloped a  certain  confidence  in  the  nurse.  She  was  able  to 
convince  him  that  he  might  be  in  a  hospital,  although  he 
objected  that  there  were  no  wounded  there.  (He  was  in  a 
mental  section  where  there  were  no  bandaged  men.)  All 
the  while  he  was  very  hard  of  hearing  and  shouted  loudly  in 
speech.  For  twelve  days  he  could  not  be  convinced  that  he 
was  in  Germany.  The  fact  that  the  Sister  was  speaking 
German  was  met  promptly  by  the  fact  that  in  France  the 
physicians  and  Sisters  spoke  German  too. 

An  extraordinary  change  came  over  him  January  27 
(sixteen  days  after  admission).  He  went  into  the  garden, 
apparently  deaf  and  shouting  his  answers,  accompanied  by 
Sister  Margarethe,  whom  he  always  called  "Sister  Anna" 
and  whom  he  thought  came  from  Lichterfelde.     While  walk- 


SHELL-SHOCK:    NATURE   AND   CAUSES  495 

ing  with  the  Sister,  his  condition  suddenly  disappeared.  He 
began  to  hear;  he  spoke  in  a  normal  tone,  in  fact,  rather  low, 
and  began  to  address  the  Sister  by  her  right  name,  Mar- 
garethe.  He  was  astonished  at  the  snow  in  the  garden,  and 
asked  the  Sister  whether  she  noticed  that  the  artillery  had 
just  stopped  firing.  Gradually  getting  his  bearings,  he  won- 
dered whether  he  had  been  in  the  hospital  since  the  day 
before.     He  certainly  was  not  ill,  he  thought. 

This  normal  state  lasted  for  a  half  hour.  The  patient  then 
relapsed  into  anxious  semi-consciousness,  becoming  deaf 
again  and  shouting  his  words.  During  the  next  few  days 
and  weeks  he  had  frequent  changes  of  state  like  the  above 
described.  The  changes  to  a  normal  state  would  take  place 
spontaneously  in  the  absence  of  apparent  occasion,  but  the 
relapses  into  semi-consciousness  took  place  when  there  was 
some  outer  irritation,  especially  some  noise.  Every  fright 
would  cause  a  relapse.  Once  a  small  cannon  fired  at  a  great 
distance  off  caused  such  a  relapse;  again,  a  sudden  shouting 
at  the  patient. 

During  the  clear  state  there  was  a  complete  amnesia  for 
the  period  of  illness.  He  did  not  want  to  believe  that  he 
had  been  in  the  hospital  for  weeks,  declaring  that  he  must 
have  been  in  the  trenches  two  days  before. 

Gradually  the  semi-conscious  states  decreased  in  length; 
the  deafness  and  loud  speech  returned  with  the  semi-con- 
sciousness. With  the  return  of  orientation,  the  man  looked 
entirely  normal,  speaking  in  a  low  voice  somewhat  shyly. 
He  was  rather  suspicious  and  could  find  his  way  about  with 
difficulty.  His  memory  broke  off  with  the  last  days  of 
December,  1914,  at  which  time  he  was  in  the  trenches  under 
intense  shell  fire.  His  wife  had  received  no  word  from  him 
since  December  26.  Even  at  the  beginning  of  February  he 
grew  anxiously  tense  when  the  word  shell  was  mentioned. 

February  4,  Gaupp  presented  him  in  clinic  as  entirely 
clear.  He  mentioned  that  his  relapses  to  semi-consciousness 
occurred  on  the  occasion  of  a  loud  noise  or  word  spoken. 
His  face  was  contorted  at  Gaupp's  remark  but  there  was  no 
other  change  in  him.  The  next  day,  however,  he  told  the 
Sister  that  Gaupp  had  shouted  out  once  to  "get  him  away." 


496  shell-shock:  nature  and  causes 

He  said  he  had  then  heard  artillery  fire  for  a  moment,  but 
pulled  himself  together  though  he  had  almost  gone  off,  and 
had  a  violent  headache  afterward. 

These  states  of  alternating  normality  and  semi-conscious- 
ness continued  until  about  February  lo.  During  a  clear 
spell,  the  patient  was  quiet,  reserved,  taciturn,  a  little  ill- 
tempered  and  seclusive,  occasionally  writing  his  wife  a  rather 
empty  letter.  In  the  semi-conscious  state  he  was  emotional 
and  restless,  seeking  cover  from  the  enemy.  These  states 
stopped  altogether  about  the  middle  of  February.  He  then 
became  somewhat  more  open,  though  he  had  no  idea  of  the 
gravity  of  his  condition.  He  was  angered  by  the  window- 
bars,  and  offended  by  the  opening  of  a  letter  to  his  wife,  de- 
claring that  he  would  never  write  a  word  again,  as  it  was  just 
like  a  prison.  These  outbursts  passed  quickly  by.  He 
wanted  to  go  home  and  believed  he  would  soon  be  able  to  go 
to  his  comrades  in  the  field. 

At  the  time  ofthe  report,  Gaupp  felt  that  he  could  not  be 
discharged  for  a  number  of  weeks.  He  was  pallid,  gave  the 
impression  of  being  exhausted  mentally,  complained  of  rest- 
lessness and  internal  irritation.  His  memory  gap  covered  at 
the  end  of  March  a  period  of  about  five  weeks :  from  the  end 
of  December,  1914,  to  the  beginning  of  February,  1915. 


SHELL-SHOCK:    NATURE  AND   CAUSES  497 


Frostbite ;  thrown  into  water  by  horse ;  horse  shot 
under  its  rider  who  becomes :  A  HORSE  IN  THE 
UNCONSCIOUS. 


Case  359.     (Eder,  March,  1916.) 

A  private  in  the  Royal  Engineers,  25,  went  through  Gal- 
lipoli  without  injury  and  without^fears.  He  was  sent  to  the 
hospital  in  Malta,  December  18.  When  observed  by  Eder, 
February  7,  the  frostbitten  finger  of  the  right  hand  was  well 
although  there  was  some  loss  of  grip.  He  was  suffering  from 
insomnia,  terrifying  dreams,  shaky  hands.  It  seems  that 
December  6,  a  horse  started  and  he  was  thrown  into  the 
water  from  a  bridge.  The  next  day  his  horse  was  shot  under 
him.  A  few  days  later,  a  finger  was  frostbitten.  Then  his 
hands  began  to  tremble  and  the  insomnia  set  in,  with  severe 
headaches. 

This  patient  was  a  jovial,  thickset,  farmer's  son,  with  a 
diffuse  enlargement  of  the  thyroid  gland,  a  high  blood  pres- 
sure, lymphocytosis,  a  fine  tremor  of  the  hands,  irregular  and 
rapid  pulse,  and  anginal  attacks.  Extremities  were  cold  and 
blue;  the  palms  perspired  markedly;  there  was  hypersen- 
sitiveness  to  sound;  there  were  occasional  attacks  of  dizzi- 
ness, with  a  feeling  of  suffocation;  there  was  frequent  desire 
to  micturate. 

The  patient's  dream  was  always  the  same:  He  saw  a 
Frenchman  digging  a  knife  into  his  horse,  getting  off  a  cart 
to  do  this  somewhere  in  Serbia.  Occasionally  he  had  this 
dream  in  the  form  of  a  vision  in  the  daytime.  It  seems  that 
he  had  actually  seen  a  French  soldier  plunge  a  knife  into  a 
mule  to  make  it  go.  He  had  been  busy  with  horses  since 
childhood:  as  stableboy  and  groom.  He  thought  that  the 
sufferings  of  the  mules  in  Gallipoli  were  worse  than  those  of 
human  beings.  According  to  Eder,  this  farmer's  son  was  the 
horse  of^his  dreams ;  instinctive  fear  had  to  emerge ;  he  was 
pitying  himself.  According  to  Eder,  "That  the  person  should 
become  a  horse  in  the  unconscious  would  not  startle  one  who 
has  dipped  into  the  totems  and  taboos  of  the  lower  races." 


498  shell-shock:  nature  ani>  causes 


Shell-shock;  gassing;  fatigue:  Anesthesias. 


Case  360.     (^Myers,  March,  1916.) 

A  stretcher-bearer,  44,  eleven  ^ears  in  the  service  and  two 
months  on  French  service,  was  seen  by  Lt.  Col.  ]\Iyers  eight 
days  after  reporting  sick  and  admission  to  a  base  hospital. 

While  he  was  under  cover  in  a  cellar,  three  days  before 
reporting  sick,  a  shell  had  jammed  the  door  and  the  fumes 
came  in.  Later  in  the  day,  in  another  cellar,  he  had  been 
blown  off  his  seat  by  a  shell  and  sLx  other  men  had  been  laid 
out.  The  shelling  continued  that  day  and  two  following 
days.     He  had  worked  on  the  wounded  without  any  rest. 

On  King  down  he  found  his  left  arm  numb  and  cold.  The 
numbness  then  spread  to  the  legs,  especially  to  the  left  leg. 
There  was  continual  tingling  in  terminal  joints  of  fingers  of 
left  hand;  hypalgesia  over  both  forearms  and  hands,  espe- 
cially on  left  side;  total  analgesia  over  left  dorsum. 

Two  days  later,  the  patient  could  feel  articles  and  reported 
that  the  numbness  occurred  only  in  the  early  morning  and 
was  followed  by  a  tingling  as  the  numbness  passed  off.  On 
the  same  day,  the  hands  and  forearms  showed  a  total  loss 
of  sensibility  to  pain,  except  for  a  small  area  on  the  flexor 
surface  below  the  elbow  joint. 

Re  spread  of  anesthesia  and  alternation  of  sensory  symptoms 
in  this  case.  Babinski,  of  course,  believes,  that  the  majority 
of  these  conditions  are  the  product  of  medical  suggestion,  but 
Babinski  meets  any  critique  by  pointing  out  that  any  [other 
sort  of  suggestion  may  produce  such  results.  The  hetero- 
suggestion  need  not  be  medical.  Thus,  the  sight  of  a  com- 
rade with  paralysis  or  anesthesia,  organic  or  hysterical,  may 
suggest  such  to  the  soldier.  Leri  remarks  that  these  may 
also  be  produced  by  autosuggestion  alone.  "From  a  tired 
feeling  in  a  limb  to  a  loss  of  power  in  it,  there  is  but  a  small 
step.  Another  step  leads  to  paralysis  and  anesthesia.  The 
neuropathic  temperament  takes  these  small  steps  in  per- 
fectly good  faith."  Leri  has  found  no  case  in  which  he  could 
exclude  the  influence  of  auto-  or  heterosuggestion. 


SHELL-SHOCK:  NATURE  AND  CAUSES         499 


Shell-shock;   burial;    somnambulistic   state:   Am- 
nesia.    Recovery  of  memory  in  hypnosis. 


Case  361.     (Myers,  February,  1915.) 

A  healthy-looking  man,  with  flushed  face  and  large  dark  eyes 
with  wide  pupils,  complained  of  pains  in  abdomen,  back,  and 
limbs,  chiefly  in  knees  and  ankles,  and  of  visual  impairment. 
This  corporal  said  that  his  sight  had  been  very  indistinct 
since  he  was  buried,  and  that  if  he  looked  at  an  electric  light, 
he  could  see  nothing  for  five  minutes  afterwards.  He  was 
admitted  to  the  Duchess  of  Westminster's  War  Hospital  at 
Touquet,  December  11,  1914,  having  been  burled  for  48 
hours,  December  8,  when  a  shell  blew  in  the  trench  where  he 
lay.  He  said  he  could  remember  nothing  until  he  found 
himself  in  a  dressing  station,  lying  on  straw.  In  a  barn.  He 
was  at  that  time  unable  to  see  and  fell  over  something  when 
he  tried  to  walk. 

He  had  gone  out  August  13,  and  had  been  in  the  last  two 
days  at  Mons  and  then  at  La  Bassee.  He  had  slept  badly 
and  had  taken  a  good  deal  of  whiskey.  He  had  led  a  fast 
life  and  had  had  domestic  worries  recently. 

It  appeared  that  his  vision  had  Improved  since  the  day 
of  the  explosion;  though  he  could  read  for  a  short  time  only 
when  things  became  blurred,  and  only  with  the  type  close  to 
the  eyes.  Bowels  had  not  opened  for  five  days.  Vision  in 
right  eye  was  5/60;   left  eye,  2/60. 

Tested  for  smell,  he  failed  to  smell  peppermint,  ether, 
iodin  tincture,  and  carbolic  acid  1-40.  Sugar  was  tasted 
only  after  tongue  movements  were  permitted,  as  was  also  a 
strong  solution  of  salt.  Acid  tasted  salty  like  alum.  The 
patient  complained  that  he  did  not  sleep,  though  in  point  of 
fact  he  slept  well. 

The  patient  was  treated  by  suggestion,  both  in  hypnosis 
and  without,  when  he  was  transferred  on  the  31st  of  Decem- 
ber, to  the  London  Temperance  Hospital,  whence  he  was 
discharged.  The  treatment  by  suggestion  occurred  daily. 
At  the  second  trial  and  thereafter,  light  hypnosis  was  easily 


500  SHELL-SHOCK:    NATURE  AND   CAUSES 

induced,  but  the  deeper  stages,  with  hallucinations,  anes- 
thesia, and  post-hypnotic  anesthesia,  could  not  be  reached. 
The  lighter  stages  brought  about  sleep,  a  gradual  restoration 
of  memory,  and  later  an  improvement  in  visual  and  olfactory 
acuity;  in  near  vision,  in  visual  fields,  and  in  color  sensibility. 

The  stages  in  the  restoration  of  memory  are  as  follows: 
December  22,  he  was  able  to  describe  how  he  was  buried, 
how  Sergeant  L,  dug  him  out,  how  men  of  another  regiment 
than  his  own  took  him  to  a  dressing  station,  whence  he  was 
packed  off  by  the  M.  O.  to  the  dressing  station  of  his  own 
regiment.  Capt.  S.  had  spoken  to  him  and  given  him  a 
drink.  Post-hypnotic  suggestion  caused  him  to  remember 
this  latter  fact  after  he  had  come  out  from  hypnosis. 

December  23,  even  before  hypnosis,  he  could  remember 
a  big  hospital  with  a  stove  in  the  center  of  a  big  square  room, 
and  gave  a  fragmentary  account  of  struggling  in  the  trench 
after  being  buried,  and  of  going  to  sleep  and  enjoying  him- 
self at  home,  when  somebody  started  messing  him  about. 
In  hypnosis,  he  gave  further  details  of  his  dreams  after  fall- 
ing asleep  in  the  buried  state. 

December  26,  further  details  were  remembered  before 
hypnosis,  such  as  a  ride  in  the  motor  ambulance,  offers  of 
tea,  cocoa,  sweets,  and  cigarettes,  a  bad  headache,  and  the 
like. 

December  27,  in  hypnosis,  he  w^as  able  to  describe  with 
apparent  accuracy  the  position  of  the  trenches  and  their 
appearance.     He  said: 

"The  explosion  lifted  us  up  and  dropped  us  again. 
It  seemed  as  if  the  ground  underneath  had  been  taken 
away.  I  was  lying  on  my  right  side,  resting  on  my 
right  hand,  when  the  shell  came.  I  got  my  right  hand 
loose  but  my  wrist  was  fixed  behind  a  piece  of  fallen 
timber.  At  last  I  dropped  off  to  sleep  and  had  funny 
dreams  of  things  at  home.  One  thing  in  particular  I 
have  thought  of  many  times  since,  I  have  not  been  able 
to  make  out  why  I  should  dream  of  the  young  lady 
playing  the  piano.  I  don't  know  her  name  and  I  don't 
think  I  have  seen  her  above  twice." 

According  to  Myers,  it  is  questionable  how  far  the  patient's 
memory  can  be  trusted;    and  there  is  considerable  doubt 


SHELL-SHOCK:    NATURE  AND  CAUSES  50I 

whether  the  man  had  remained  in  the  trench  for  more  than 
an  hour  after  the  shell  had  burst.  A  comrade  said  that  the 
doctors  at  the  barn  thought  the  man  off  his  head.  Another 
soldier,  familiar  with  the  positions  of  the  regiments  in  ques- 
tion, gave  information  suggesting  that  the  patient  had  wan- 
dered in  a  somnambulistic  state  from  the  trench,  past  his  own 
dressing  station  to  that  of  another  regiment. 

Re  Shell-shock  and  burial  cases,  compare  remarks  of 
Grasset  and  of  Foucault  concerning  the  feeling  as  if  dead  on 
the  part  of  certain  buried  persons.  Somnambulism  is  a 
natural  sequel  to  such  feelings.  For  somnambulism,  com- 
pare cases  of  Milian  (364,  365,  and  366). 


502  SHELL-SHOCK:    NATURE  AND  CAUSES 


Shell-shock;      minor     injuries:      Somnambulistic 
**  carrying  on  " ;  fatigueability,  physical  and  mental. 


Case  362.     (DoNATH,  July,  1915-) 

A  lieutenant  of  infantry,  31,  threw  himself  down  on  the 
earth  September  9,  1914,  as  a  shell  was  passing  over  him.  The 
shell  exploded  and  seriously  injured  a  soldier  one  meter  away. 
The  lieutenant  got  up  and  ran  for  cover  about  twenty  meters 
distant.  Only  six  and  a  half  hours  later  did  he  perceive  that 
there  was  a  small  skin  lesion  between  his  thumb  and  index 
finger,  caused  by  a  shell  fragment,  as  well  as  a  superficial 
burn  on  his  right  temple.  Neither  wound  bled  or  had  to  be 
dressed.  He  carried  on,  aware  that  they  were  marching 
toward  the  River  D.;  but  only  two  or  three  days  later  did 
he  find  they  had  already  marched  to  the  other  side  of  K.,  had 
rested  there  and  spent  the  night  in  various  places  in  between. 
During  this  whole  period  the  lieutenant  led  his  battalion  and 
held  a  piece  of  woods  without  anyone's  noticing  anything 
striking  about  him.  These  dazed  states  were  twice  repeated, 
for  periods  of  ten  and  twenty-four  hours  respectively,  and 
finally  he  was  brought  behind  the  firing  lines  unconscious. 

The  physician  found  him  to  be  in  a  state  of  exhaustion, 
pulse  108,  and  had  him  brought  to  the  nearest  station.  There 
Donath  found  increased  tendon  reflexes,  some  dermatographia 
and  increased  fatigueability  of  mind  and  body.  He  was 
especially  fatigued  by  walking,  though  he  had  always  been  a 
good  mountain  climber.  He  was  now  unable  to  concentrate 
on  reading,  writing  or  calculating,  though  he  had  been 
accustomed  to  dictate  letters  and  calculations  in  his  official 
work  in  peace  times.  He  had  seizures  of  crying  and  trembling 
on  September  10  and  October  27,  both  quieted  by  bromides. 
There  was  diminution  of  sexual  power. 

Rest,  lukewarm  baths,  cold  compresses  to  the  head,  and 
psychotherapy  improved  his  status  rapidly. 

This  patient  had  never  been  epileptic  or  hysterical,  subject 
to  dazed  states  of  any  sort,  was  weak,  delicate  and  anemic 
(three  sisters  leukemic),  but  had  before  the  war  been  well. 


SHELL-SHOCK:  NATURE  AND  CAUSES         503 


Emotion  of  captain  who  saw  men  burned  by  bomb : 
Stupor  "  as  if  dead  " ;  awakening  **  as  if  a  German 
prisoner."     Recovery. 


Case  363.     (Regis,  May,  1915.) 

A  captain,  one  day  seeing  some  of  his  men  hit  by  incendiary 
bombs,  felt  the  deepest  kind  of  emotion.  He  threw  his  coat 
over  one  of  his  men  and  succeeded  in  smothering  the  fire. 
Of  a  sudden,  he  completely  lost  consciousness,  only  regaining 
contact  with  the  outer  world  two  days  later,  in  the  sanitary 
train.  He  did  not  know  where  he  was,  but  thought  himself 
a  prisoner  surrounded  by  Germans.  The  disorder  of  con- 
sciousness lasted  three  days,  and  the  memory  of  what  hap- 
pened during  those  days  never  returned.  In  fact,  the 
captain  declared  that  he  felt  as  if  he  had  been  dead  during 
that  time.  His  dreamlike  state  lasted  for  some  time,  and  for 
several  weeks  he  did  not  sleep  without  disturbing  nightmares. 
It  was  always  the  same  night  attack,  with  the  burned  men 
and  the  anguish  of  feeling  that  his  men  were  not  about  him 
and  that  he  was  alone  In  the  skirmish.  He  later  recovered 
entirely  and  made  preparations  to  start  for  the  front. 

Re  feelings  "as  if  dead,"  see  remarks  of  Regis  under  Case 
293- 


504  SHELL-SHOCK:    NATURE  AND   CAUSES 


Emotions  over  battle  scenes :  Spontaneous  hypnosis 
or   SOMNAMBULISM   lasting  twenty-four  days. 


Case  364.     (MiLiAN,  January.iQis.) 

Upon  recovery  from  a  state  of  apparent  hypnosis  described 
below,  the  victim  wrote,  in  part,  as  follows: 

"  After  marching  two  days  we  reached  a  Breton 
village  near  Virtou.  Next  day  we  were  in  a  battle  that 
lasted  from  seven  in  the  morning  to  eight  in  the  evening. 
I  was  somewhat  troubled  by  the  first  balls  and  bullets 
that  whistled  by,  but  felt  I  had  to  get  used  to  them  and 
we  marched  on,  under  our  brave  captain's  orders. 
Then  we  really  got  under  fire.  It  was  sad  to  see  my 
comrades  falling  under  the  murderous  bullets,  and  the 
captain  was  soon  mortally  wounded;  but  we  had  re- 
inforcements and  went  on  and  chased  the  enemy  from 
his  positions.  During  the  battle  I  kept  thinking  of 
my  old  mother  and  father  and  I  felt  that  I  should  die 
without  seeing  them  again.  Little  things  about  the 
family  came  to  my  mind.  I  saw  my  father's  roof,  and 
his  favorite  garden  seat,  and  I  saw  my  mother  weeping 
over  her  only  son,  her  only  ambition  in  old  age.  The 
return  from  the  battle  was  very  sad  for  me.  Night  be- 
gan to  fall  on  the  frightful  field.  I  saw  on  the  bare 
earth  the  bodies  of  poor  comrades  whose  joys  and  sor- 
rows I  had  shared.  There  they  were,  cut  down  in  all 
the  strength  of  youth,  leaving  their  parents  in  trouble, 
their  widows  in  despair,  and  their  poor  orphans.  I 
wanted  to  carry  them  ofT  and  I  could  not.  We  had  to 
march  over  their  glorious  remains.  I  was  able  to  give  a 
word  of  encouragement  to  one  of  my  comrades  who  now 
probably  is  no  more.  We  then  retired.  Although  I 
was  very  weary,  I  was  unable  to  get  any  rest.  My  mind 
was  occupied  with  the  frightful  things  I  had  seen.  I 
thought  of  the  comrades  over  there  and  that  no  one 
could  help  them.  I  remember  I  drank  coffee  the  next 
morning  and  talked  with  my  relative.  Then  that  is  all. 
From  that  time  I  do  not  know  what  happened." 

The  writer  was  an  infantryman,  20,  who  had  been  employed 
in  civil  life  in  the  Credit  Lyonnais,  and  was  brought  August  24, 
191 4,  to  the  Saint  Nicolas  Hospital  in  a  state  of  hypnosis. 


SHELL-SHOCK:    NATURE  AND  CAUSES  505 

Once  placed  in  the  standing  position  he  kept  balancing  back 
and  forth,  with  head  motionless,  eyes  fixed  and  directed  to  the 
left  side.  He  did  not  speak  in  reply  to  a  request  for  his  name 
or  facts  about  his  life,  but  as  soon  as  the  battle  was  talked  of  he 
began  an  expressive  pantomime,  speaking  in  a  very  low  voice 
a  few  words  interrupted  by  sighs.  "  What  were  you  doing  in 
the  fight?  "  He  extended  his  arms,  described  a  half  circle 
with  his  hand,  as  if  to  show  the  extent  of  the  field,  thrust  his 
hands  forward  with  a  finger  outstretched,  saying,"  Zi,  zi,"  as 
if  to  indicate  whistling  bullets;  plunged  forward  with  hands 
in  front  of  his  chest,  as  if  holding  a  gun  in  charge  bayonet 
position,  saying  "  Prussians,  Prussians,"  and  threw  himself 
down  in  a  kneeling  posture,  saying,  "  Trenches,  trenches." 
"Do  you  remember  the  battle?"  "Belgium,  Belgium. 
Germans  pushed  back,"  making  a  sign  as  if  chasing  them. 
"Captain  dead.  Two  hundred  men  dead."  With  a  suitable 
gesture  he  sighed,  and  tears  ran  down  his  face. 

August  28  the  mutism  was  still  almost  complete,  but  he 
could  say  his  name  and  lay  stretched  out  on  the  bed. 

September  4  the  hypnosis  was  less,  but  the  delirious  state 
was  more  active.  He  got  up  in  the  night  and  tried  to  escape 
to  help  the  wounded.  In  the  daytime,  if  he  saw  a  man  lying 
down  resting  he  went  to  him  and  unbuttoned  his  coat  to  see 
whether  he  was  wounded.  Upon  seeing  the  physician  he 
would  cry,  "Major!  Wounded!  wounded!"  and  then  pull 
the  physician  by  his  coat.  He  could  hardly  be  stopped  from 
these  maneuvers.  He  had  to  be  fed  like  a  child,  but  went 
alone  to  stool. 

He  began  to  be  employed  about  the  hospital  a  little 
September  14,  in  sweeping  the  room  and  in  guarding  another 
patient  in  complete  somnambulism,  over  whom  he  watched 
as  over  a  child,  leading  him  by  the  hand  and  keeping  him 
from  bumping  into  objects. 

September  16  he  awoke  suddenly.  Some  one  had  talked 
to  him  about  his  own  village  and  his  relatives.  He  was  aston- 
ished to  find  himself  in  a  hospital.  He  wrote  out,  on  request, 
the  above  account  of  his  recollections.  The  man  was  177  cm. 
tall,  well  proportioned;  showed  a  slight  facial  asymmetry  and 
a  few  other  facial  features  of  a  dystrophic  nature,  such  as  an 
adenoid  appearance.     There  was  no  stigma  of  hysteria. 


506  SHELL-SHOCK:    NATURE  AND   CAUSES 


Putative  loss  of  brother  nearby  in  battle:  Spon- 
taneous hypnosis  or  somnambulism ;  mutism,  except 
**  Mamma,  Mamma."  Sudden  awakening  after 
twenty-seven  days. 


Case  365.     (MiLiAN,  January,  191 5.) 

A  man,  22,  was  brought  to  the  Saint  Nicolas  Hospital  in 
a  sort  of  coma  August  24,  1914.  He  lay  on  the  bed,  eyes 
closed  as  if  asleep,  insensible  to  excitation,  irresponsive. 
Flies  crawled  upon  him  with  impunity.  He  did  not  wink. 
The  arms  raised  fell  back  inert.  The  corneal  reflex  was 
absent  on  the  left  side,  diminished  on  the  right.  The  knee- 
jerks  and  the  skin  reflexes  were  normal. 

Next  day  he  had  to  be  fed  like  a  child  and  looked  after. 
Lifted  from  bed,  once  on  the  ground  he  stood  up  with  flexed 
legs,  as  if  to  crouch.  It  seemed  as  if  he  was  about  to  fall,  but 
he  did  not. 

The  next  day  he  was  in  the  same  immobile  state.  Upon 
removal  from  bed  he  again  made  as  if  to  fall,  but  got  his 
balance.  He  kept  his  legs  flexed,  his  head  lowered  in  a  fixed 
posture,  with  his  eyes  on  the  ground.  He  would  walk  quickly 
without  falling,  if  taken  by  the  hand,  feet  dragging,  and  even 
holding  back  with  a  certain  amount  of  force.  His  walk 
suggested  that  of  a  somnambulist.  He  was  left  in  a  standing 
posture  by  his  bed  throughout  the  medical  visit.  After  a  few 
minutes  he  began  to  flex  his  legs  progressively  and  slowly. 
The  attendant  cried  out,  "He  Is  going  to  fall."  Instead  of 
falling,  he  sat  down  upon  the  floor  near  the  bed.  He  was  in 
the  same  immobile,  somnolent  state  September  i,  eyes  half 
open,  hidden  under  long  lashes.  Flies  walked  over  his  eyes 
and  lids,  but  he  did  not  wink.  He  would  rise  only  when 
pushed  and  walk  only  when  pulled,  but  had  begun  to  eat  a 
little  better.  To  all  questions  he  replied,  from  between  his 
teeth,  "Mamma.     Mamma." 

The  next  day  there  was  a  bit  more  spontaneity  in  his 
walking. 

Lumbar  puncture  showed  a  slight  hypertension.  There 
were  traces  of  albumin  and  very  few  lymphocytes. 


SHELL-SHOCK:    NATURE  AND  CAUSES  507 

September  6,  he  was  able  to  eat  soup  alone,  but  kept 
the  same  immobile  posture,  with  eyes  fixed  on  the  ground, 
eyelids  not  winking,  in  a  posture  suggesting  Parkinson's 
disease,  but  without  rigidity.  He  still  replied  only, ' '  Mamma. 
Mamma." 

September  19  the  patient  suddenly  waked  up  completely. 
Douches  and  external  irritations  had  not  served  to  wake  him 
up,  but  a  soldier  told  him  upon  this  day  that  his  brother  was 
not  dead,  as  he  believed,  but  was  alive  and  he  then  began  to 
speak,  opened  his  eyes,  and  began  to  talk.  He  told  how  he 
had  been  by  the  side  of  his  brother  in  battle.  Germans  had 
taken  them  in  the  flank  and  opened  machine  guns  upon  them. 
Two  men  had  fallen  by  his  side,  and,  catching  at  his  garments, 
kept  him  from  retiring  when  the  order  was  given.  He  got 
loose,  looked  for  his  brother  among  the  corpses,  could  not 
find  him,  thought  him  dead,  and  from  that  point  forward 
had  been  without  memory.  He  shortly  became  perfectly 
normal. 


5o8  shell-shock:  nature  and  causes 


Shell-shock;  slight  trauma;  windage  felt;  fall;  loss  of 
consciousness;  wandering,  conscious,  over  night; 
shrapnel  burst :  Spontaneous  hypnosis  or  somnam- 
bulism, lasting  four  days.     Return  to  the  corps. 


Case  366.     (MiLiAN,  January,  191 5.) 

An  infantryman,  20,  boxer  by  profession,  was  brought  with 
other  wounded,  in  the  night,  to  Saint  Nicolas  Hospital  and 
was  seen  next  morning,  August  24,  in  bed,  lying  motionless 
on  his  back,  eyes  open,  fixed,  eyelids  not  winking.  No  reply 
was  got  to  questions.  The  arm  lifted  fe  1  back  upon  the 
bed,  although  slowly  and  not  heavily  as  in  apoplexy.  There 
was  no  catalepsy.  The  patient  was  taken  from  his  bed  and 
put  upright.  In  this  position  he  remained  immobile,  hands 
at  side,  head  bent  forward,  eyes  fixed  on  the  ground.  The 
eyelids  did  not  move  upon  approach  of  the  finger  or  a  lighted 
candle,  unless  there  was  a  fine  beginning  of  movement.  If  he 
was  pushed,  he  made  two  or  three  steps  forward,  with  eyes 
fixed  on  the  ground  and  head  bent  forward.  The  only 
spontaneous  movement  was  carrying  the  left  hand  back  to 
the  side  as  if  to  take  the  bayonet.     He  got  into  bed  alone. 

Next  day  the  patient  could  walk  better  and  began  to  talk, 
but  preserved  the  same  absorbed  attitude.  He  told,  in 
monotonous  voice,  of  the  shells  that  his  squad  had  received 
and  of  the  dead  that  he  saw  about  him.  August  27  he  woke 
up  and  was  unable  to  tell  how  he  had  come  to  the  hospital. 
He  told  how  the  regiment  had  been  bombarded  for  a  time 
and  how  a  shell  burst  near  him ;  how  he  got  a  splinter  in  the 
buttock  (of  which  the  contusion  was  still  visible) ;  and  how 
he  had  been  thrown  down  by  the  windage  of  the  shell.  His 
sack  had  been  torn  from  his  shoulders.  He  had  lost  con- 
sciousness, he  thought,  for  a  short  time,  anyhow  he  could  not 
find  his  regiment.  He  passed  the  night  near  Longuyon  and 
next  day  looked  for  his  regiment  again.  Shrapnel  burst  near 
him,  and  from  that  time  forward  he  had  lost  memory.  Aug- 
ust 27,  at  his  express  request,  he  started  back  for  his  corps. 
There  was  no  stigma  of  degeneration  or  hysteria. 


shell-shock:  nature  and  causes  509 


Burial ;  struck  in  head  by  beam ;  overcome  by  gas : 
Tremors,  convulsive  movements,  confusion,  flight 
toward  enemy. 


Case  367.     (CoNsiGLio,  1916.) 

An  Italian  private,  28,  of  meager  build  (infantile  eclampsia; 
brother  epileptic)  was  buried  by  a  shell  explosion  and  over- 
come by  gas.  After  a  month's  leave  he  went  back  to  the 
trenches. 

But  now,  whenever  a  shell  burst,  he  fell  into  irresistible 
terror  and  made  convulsive  movements  which  he  forgot  after- 
wards. He  could  not  sleep.  The  mere  memory  of  the  scene 
would  throw  him  into  terror.  He  was  tremulous,  developed 
asymmetrical  innervation  of  his  face,  was  generally  hyp- 
esthetic  and  mentally  blocked. 

In  the  midst  of  convulsive  tremors  he  fled  towards  the 
enemy.  He  was  stopped  and  brought  back,  and  remained 
for  two  days  confused  and  hallucinated. 

In  the  original  accident  he  had  been  struck  in  the  head 
by  a  beam. 

Re  this  Italian's  flight  toward  the  enemy,  see  various  cases 
of  fugue.  Clinically  and  medicolegally,  Roussy  and  Lher- 
mitte  remark  that  these  confusional  escapades  are  of  great 
interest,  and  that  many  cases  are  encountered  near  the 
front  line,  put  under  trial  by  court-martial,  and  handed 
over  to  specialists.  The  dream  is  being  lived  through. 
Such  a  case  as  this  of  Consiglio  recalls  the  hystero-emotional 
psychoses  of  Claude,  Dide,  and  Lejonne.  The  relation  of 
oniric  delirium  to  mental  confusion  is  still  a  matter  of  polemic. 
According  to  Regis,  however,  the  common  oniric  delirium  of 
toxic  or  infectious  origin  is  nothing  more  than  a  sort  of 
somnambulism.  The  retrograde  amnesia  which  follows  toxic 
delirium  is  the  same  in  principle  as  that  which  follows 
hysterical  delirium.  Regis  pointed  out  that  suggestive  hyp- 
nosis could  bring  back  the  memories  in  both  types  of  disease, 
as  well  as  from  the  toxic  delirium  as  from  the  hysterical  som- 
nambulism. However,  the  differential  diagnosis  between 
onirism  and  hysteria  is  not  easy.  Alcoholism  and  actual 
brain  trauma  need  to  be  excluded. 


510  SHELL-SHOCK:    NATURE   AND  CAUSES 


Shell-shock;  windage;  unconsciousness:  Carried 
on  with  fugue  tendencies.  Variety  of  hysterical 
symptoms.  Fit  for  garrison  duty  four  months  from 
explosion. 


Case  368.     (BiNSWANGER,  July,  191 5.) 

A  non-commissioned  officer,  22,  entered  serv^ice  at  20,  went 
into  the  artillery  and  had  been  advanced  repeatedly.  There 
was  no  heredity;  the  man  had  been  a  moderately  good 
scholar.  It  appears  that  he  had  had  at  17  a  febrile  angina 
with  delirium. 

September  25,  1914,  a  big  shell  load  for  a  cannon  was 
exploded  by  the  enemy.  All  the  men  about  the  cannon  were 
thrown  to  the  ground  by  air  pressure,  and  the  officer  became 
unconscious.  On  awaking,  he  had  headache,  dizziness,  and 
vomiting.     There  were  many  corpses  lying  about  him. 

He  resumed  work  at  once,  but  in  the  evening  his  headache 
and  dizziness  increased  and  there  was  "a  feeling  inside  as  If 
he  had  to  run  away."  This  feeling  appeared  to  come  from 
the  heart;  it  was  an  oppressive  feeling,  running  to  the  head. 
On  the  next  day  he  did  gun  duty,  noticing,  however,  that 
every  shot  he  fired  caused  him  a  sharp  pain.  He  was  relieved 
from  work  at  11  a.m.,  and  was  declared  ill  by  the  physician. 
His  comrades  told  him  that  he  had  often  been  noticed  trying 
to  run  away,  but  about  this  he  himself  declared  he  knew 
nothing. 

He  was  received  at  the  Jena  Hospital,  October  9,  1914,  a 
very  strongly  built  and  well-nourished  man.  Neurologlcally, 
he  showed  a  marked  dermatographia ;  knee-jerks  were 
obtainable  only  on  reinforcement;  Achilles  jerks  somewhat 
more  marked ;  there  was  a  weakly  positive  Oppenheim  reflex. 
The  abdominal  reflex  on  the  left  side  was  greater  than  that 
on  the  right;  and  this  was  also  true  of  the  cremaster  reflex. 
Percussion  of  the  head  was  extremely  painful ;  and  there  were 
painful  points  on  pressure  of  the  spine  and  head. 

Touch  was  poor  on  the  entire  left  side  of  the  body;  but 
there  was  no  diminution  of  sensibility  to  pain.     There  was 


SHELL-SHOCK:  NATURE  AND  CAUSES         5II 

a  fine  static  tremor  of  the  hands.  The  strength  of  both 
hands  appeared  to  be  decreased  (dynamometer).  Gait  was 
unsteady  and  sti£f;  Romberg  sign  was  positive;  the  patient 
fell  over  backward.  Hearing  was  greatly  diminished,  ordi- 
nary speech  being  heard  only  close  to  the  ear. 

Toward  evening  of  the  second  day  after  admission,  there 
was  a  marked  attack  of  dizziness  while  the  patient  was  lying 
on  his  back  in  bed.  During  this  attack  the  face  was  very 
red.  It  lasted  two  or  three  minutes.  Hearing  was  remark- 
ably improved  on  the  left  side  for  some  time  after  the  attack. 
The  ear  clinic  examination,  October  19,  showed  much  dis- 
turbance of  hearing  on  the  right  side  (direct  injury  of  the 
vestibular  apparatus  in  both  ears). 

Headaches  continued,  radiating  from  the  orbit  to  the  top 
of  the  head,  and  sensitiveness  to  pressure  at  the  exit  point 
of  the  upper  branch  of  the  right  trigeminal.  The  whole  of 
the  forehead  was  somewhat  red  and  swollen  (neuralgia  of  the 
frontalis).  The  patient  wore  dark  goggles  on  account  of  his 
marked  photophobia. 

Improvement  was  gradual;  there  was  a  transient  slight 
swelling  and  a  venous  hyperemia  of  the  nasal  mucosa,  which 
was  treated  in  the  nose  clinic.  The  impairment  of  hearing 
was  quite  gone  in  two  months'  time,  though  buzzing  was  now 
and  then  heard  in  the  right  ear.  The  supersensitiveness  in 
the  right  upper  trigeminal  region  vanished  also.  The  patient 
was  discharged  January  21,  191 5,  fit  for  garrison  duty. 
Later  he  went  into  the  field  again. 


512  SHELL-SHOCK:    NATURE  AND   CAUSES 


Burial :  Dissociation  of  personality. 


Case  369.     (Feiling,  July,  1915-) 

The  following  are  some  stories  told  by  a  "lost  personality  " 
under  hypnosis. 

The  patient,  aged  24,  was  a  bandsman  in  the  Second 
Battalion  Wiltshire  Regiment,  who  sometime  near  the  end 
of  October  1914,  was  buried  in  a  trench  near  Ypres.  This 
is  his  account: 

"  I  was  dug  out  at  night  and  taken  to  a  dressing  station;  it 
was  cold  and  dark.  Then  I  went  on  to  a  hospital  at  Ypres; 
it  was  really  a  convent,  and  there  were  a  lot  of  nuns  about, 
dressed  in  dark  robes  with  white  hats;  some  of  them  spoke 
English.  I  stopped  there  for  a  night  and  a  day.  There  were 
a  lot  of  wounded  there.  Then  I  was  sent  on  by  train;  I  lay 
down  all  the  way  on  a  seat  in  the  carriage;    we  took  the 

whole  day  to  get  to ,  and  kept  on  stopping  at  stations. 

I  was  at about  ten  days;   I  don't  know  what  hospital 

it  was,  but  there  were  English  doctors  and  nurses.  It  was 
near  the  harbor.  We  came  over  to  England  in  a  hospital 
ship,  the  Arethusa;  I  went  straight  on  to  Manchester  by 
train.  The  hospital  there  was  really  a  school  turned  into  a 
hospital. 

Here  is  a  brief  account  of  a  scrap  with  some  Uhlans. 

Q.     Did  you  see  any  Uhlans?     Yes. 

Q.  What  are  they  like?  They've  got  no  guts.  One  time 
30  of  them  were  against  8  of  us  infantry,  and  they  "done  a 
bunk."  Their  horses  were  not  bad.  They  wore  helmets 
with  a  double  eagle  on  the  front. 

He  was  asked  to  describe  the  country  round  the  trenches 
and  to  give  some  account  of  the  fighting  there : 

"It's  agricultural  land,  ploughed  fields.  There  were  two 
farms  in  front  of  us.  One  day  we  saw  an  old  cow  between 
our  trenches  and  the  Germans,  and  we  all  had  pot  shots  at  it. 
Once  the  Germans  rushed  our  trenches;  we  killed  hundreds, 
bayoneted  them  mostly,  and  hit  them  over  the  heads  with 
the  butts  of  our  rifles.  It  was  hellish.  The  British  were  all 
shouting.     I  saw  a  German  officer  behind  with  a  sword  and 


shell-shock:  nature  and  causes  513 

a  revolver.  I  saw  a  lot  of  French  soldiers,  too;  they  wore 
long  coats  with  the  corners  turned  back;  some  had  blue  and 
some  had  red  trousers.  The  French  dragoons  are  like  Life 
Guards,  with  big  steel  breastplates  and  brass  helmets  with 
a  long  plume;  they  carried  swords  and  rifles  and  a  few  had 
lances." 

He  was  asked  to  mention  some  of  his  impressions  in  Bel- 
gium and  what  he  thought  of  the  manners  and  customs  of  the 
French  and  Belgians. 

"We  cut  off  all  our  buttons  and  gave  them  to  the  French 
girls.  The  French  cigarettes  are  muck;  you  buy  them  in 
little  blue  packets;  the  tobacco  is  rather  dark  and  strong. 
When  we  bivouacked  on  the  march  at  night  we  were  not 
allowed  any  lights,  but  you  could  smoke  by  digging  a  hole  in 
the  ground  with  your  bayonet  and  smoking  into  that." 

The  following  are  some  of  his  remarks  about  his  stay  at 
Gibraltar. 

"Gibraltar's  like  a  great  big  rock;  the  steep  side  looks 
toward  Spain.  I  was  in  barracks  there,  and  used  to  spend  a 
lot  of  time  in  the  band-room  practicing.  Sometimes  we 
bathed  in  the  sea.  I  went  to  Spain  two  or  three  times  and 
saw  some  bull-fights ;  they  were  very  exciting,  but  rather  too 
cruel  for  my  taste.  They  used  to  kill  six  or  seven  bulls  a 
day.     The  horses  got  fearfully  cut  about." 

This  bandsman  showed  what  Felling  calls  dissociation  of 
personality.  There  was  an  amnesia  of  such  degree  that  all 
conscious  memories  of  the  patient's  life,  as  well  as  all  memory 
of  letters,  objects,  and  life  in  general,  were  suppressed.  The 
patient  was  brought,  after  the  burial  above  noted,  to  the 
hospital  for  epilepsy  and  paralysis  at  Maida  Vale,  January  21, 
191 5.  After  his  experience,  he  had  been  transferred  to  the 
Second  Western  General  Hospital,  Manchester,  where  he 
spoke  sensibly,  understood  and  was  able  to  remember  things 
since  the  burial.  His  mind  was  a  complete  blank  for  all 
previous  experience.  He  was  unable  to  recognize  his  own 
father  or  relatives.  He  was  slightly  deaf  for  a  time  but  this 
defect  disappeared. 

At  Maida  Vale  he  showed  a  nervous  twitching  of  eyelids 
and   facial   muscles;    otherwise  he  was  neurologically   and 


514  SHELL-SHOCK:    NATURE  AND  CAUSES 

physically  normal,  dreamless,  without  complaints,  and 
straightforward  about  all  experiences  since  coming  to  himself 
in  the  hospital  at  Manchester.  He  took  his  parents  on  trust. 
** I  don't  know  if  I  ever  went  to  school."  "A  bayonet  is  like 
a  knife;  you  see  soldiers  with  them  on  their  rifles.  I  have 
never  seen  a  bullet."  His  memory  for  recent  events  was  also 
not  good.  He  once  recognized  a  single  tune  played  at  a 
concert. 

Suspected  of  malingermg,  he  was  tried  out  in  various  ways. 
He  was  told  that  an  elephant  was  a  little  furry  animal  and 
shown  a  little  6  inch  toy  sample.  On  going  to  the  zoo  he  was 
greatly  astonished  at  seeing  a  real  elephant  He  did  not 
know  what  the  war  was  about  and  he  had  no  interest  therein. 

March  lo  he  was  hypnotized  and  proved  an  easy  subject. 
Powerful  suggestions  that  lost  memories  would  return  were 
unavailing.  The  next  day,  during  hypnosis,  it  was  found 
that  his  previous  experience  could  be  readily  tapped,  and  a 
history  of  his  family,  schooling,  running  away,  and  eventual 
enlistment  was  told.  He  had  been  at  Gibraltar  when  war 
broke  out.  He  was  at  the  first  battle  at  Ypres,  and  was  for 
ten  days  in  severe  trench  fighting,  and  was  finally  buried  in 
the  mud  and  debris  of  a  trench  blown  in  by  a  high  explosive 
shell.  He  had  been  buried  for  about  12  hours,  was  dug  out 
at  night,  and  (according  to  his  father)  remained  unconscious 
24  hours,  and  deaf  and  dumb  three  days.  He  was  trans- 
ferred to  another  hospital  and  then  to  Manchester,  where  he 
came  to  himself. 

Only  during  the  first  few  sittings  did  the  patient  lie  with 
eyes  closed.  Later,  during  hypnosis,  he  behaved  exactly  like 
a  normal  person.  The  fact  came  to  light  that  when  hypno- 
tized the  patient  returned  to  the  personality  that  possessed 
him  just  before  awakening  in  Manchester,  and  accordingly 
during  hypnosis,  he  had  to  become  acquainted  again  with  his 
hypnotizer.  Maida  Vale  astonished  him,  as  it  should  have 
been  Manchester.  Thus  there  were  two  personalities :  No.  i : 
The  personality  since  the  date  of  the  Manchester  awakening; 
No.  2:  The  personality  containing  all  the  memories  of  the 
past  life  as  well  as  the  more  recent  Flanders  memories.  In' 
State  No.  i,  the  manner  was  jaunty  and  cocksure.     In  State 


SHELL-SHOCK:    NATURE  AND   CAUSES  515 

No.  2,  the  man  was  more  modest  and  less  loud.  Moreover, 
though  in  State  No.  i,  he  spoke  with  a  Lancashire  accent,  in 
State  No.  2  his  speech  was  in  the  West  Country  dialect  —  a 
strange  observation,  confirmed  by  several  observers.  He 
was  asked  to  write  down  the  answers  to  questions,  and  on 
awakening  from  hypnosis  was  shown  the  things  written; 
whereupon  he  laughed  and  said,  "Why,  that's  not  my 
writing."  On  writing  out  the  same  sentences  again,  various 
minor  points  of  difference  were  apparent.  Hypnotized  in 
the  presence  of  his  father,  in  whom  in  State  No.  i  he  took  no 
great  interest,  he  showed  every  sign  of  joy,  causing  his  father 
to  think  that  in  State  No.  2,  his  son  had  "come  all  right 
again."  In  State  No.  2  he  could  play  a  euphonium  better 
than  in  State  No.  i ;  but  after  practicing  in  State  No.  i  he 
rapidly  became  as  expert  as  in  the  hypnotic  state. 

If  the  patient  were  left  for  some  time  before  being  awaked 
by  a  previously-arranged  method  of  counting  three,  he  would 
experience  disturbed  dreams,  with  clenched  hands,  snarling 
lips,  and  muttered  phrases,  "Give  it  them,"  etc. 

Twenty-five  hypnotic  sittings  were  given  but  no  improve- 
ment took  place  and  the  patient  was  discharged  May  5. 
May  25  there  had  been  no  further  change  and  he  remained 
in  State  No.  i,  in  which  state  he  was  invalided  from  the 
service  by  a  medical  board,  May  28. 


5l6  SHELL-SHOCK:    NATURE  AND   CAUSES 


Ear  complications  and  hysteria. 


Case  370.     (BuscAiNO  and  Coppola,  191 6.) 

An  infantryman,  22  (father  and  mother  quite  normal; 
patient  showed  sHght  convulsions,  attributed  to  worms,  from 
which  he  actually  suffered;  was  malarial  from  9  to  15;  had 
otitis  media  and  lost  hearing  completely  at  1 1 ;  had  suffered 
from  9  onwards  with  joint  pains;  as  an  adult  had  no  con- 
vulsions), was  called  to  arms  August,  1914,  and  sent  to  the 
front  May  2,  191 5.  About  the  end  of  August,  in  a  water-filled 
trench  by  Monte  San  MIchele,  he  was  covered  with  mud  from 
a  shell  explosion,  lost  consciousness,  and  in  some  way  got 
back  to  the  second  line.  He  was  told  that  blood  had  flowed 
from  the  right  ear,  and  on  recovery  he  found  himself  unable 
to  hear  with  that  ear,  although  It  was  the  left  In  which  he 
had  had  otitis.  There  were  continual  noises  In  the  ear.  He 
was,  however,  sent  back  to  the  front  line.  By  mistake,  one 
day,  he  got  with  companions  in  the  midst  of  the  enemy's 
barbed  wire,  saw  sparks  from  the  guns,  heard  no  shots,  saw 
comrades  fall,  and  threw  himself  instinctively  into  the  wire 
network.  Leaving  the  food  kettles,  he  finally  got  back  to 
the  trenches.  He  was  sent  to  the  hospital  at  Legnano  for 
his  ear  pains,  and  was  treated  by  leeches,  which  he  could  not 
feel.  He  began  to  hear  a  little  more.  Flies  walked  on  the 
left  cheek  without  being  felt.  This  anesthesia  had  begun  a 
few  days  after  the  shell  explosion.  He  was  transferred  to  a 
military  hospital  at  Florence. 

One  day  he  wedged  a  toothpick  in  cotton  Into  his  left  ear 
and  was  charged  with  simulation,  though  he  had  been  abso- 
lutely deaf  In  his  left  ear  since  childhood.  From  the  moment 
the  military  surgeon  told  him  he  would  be  denounced  for 
simulation,  he  lost  his  memory.  Reports  Indicate  that  he 
had  headache  and  delirious  dreams  (October  30),  and  sud- 
denly he  became  furious  (October  31),  about  three  hours 
later  going  into  severe  collapse,  for  which  camphor  injections 
were  given. 

November  i  he  had  battle  dreams  and  lumbar  puncture 
had  to  be  given  up  as  he  was  in  the  midst  of  an  attack.     A 


SHELL-SHOCK:    NATURE   AND    CAUSES  517 

hypodermic  injection  was  interpreted  by  the  patient  as  a 
wound,  and  he  cried  as  if  he  were  being  abandoned  on  the 
battle-field.  At  one  point  he  woke  up  from  his  hallucination 
and  asked  where  he  was  and  shortly  relapsed  into  stupor, 
November  2,  the  patient  was  slightly  bewildered  and  felt 
pains  where  the  lumbar  puncture  needle  had  been  tried  the 
previous  day.  November  5,  he  was  disoriented,  thinking 
himself  still  at  Legnano.  The  pupils  were  throughout  di- 
lated. November  6,  confused  and  dreamy;  November  7, 
he  soiled  his  bed,  was  somewhat  disoriented,  immediately 
corrected  himself;  oculo-cardiac  reflex  64  full  compression, 
62  during  compression.  November  11,  headache;  Novem- 
ber 12,  a  slight  bewilderment  reappeared;  November  13, 
remembered  for  the  first  time  having  been  stunned  by  shell 
explosion,  and  this  day  got  up  and  wrote  home.  November 
14,  complained  of  pains  in  muscles  and  weariness.  Pupils 
still  dilated.  November  16,  pulse  86;  a  gradual  increase 
from  50  to  60  during  previous  days.  November  17,  patient 
had  begun  to  remember  facts  that  preceded  the  dream  syn- 
drome. November  18,  pulse  standing  88;  November  20, 
pulse  standing  120.  This  day  cried  when  he  remembered 
having  been  suspected  of  simulation.  November  22  and  23, 
aches  in  joints  and  intense  otalgia;  pulse  86.  November 
24,  diarrhea;  deafness  somewhat  diminished;  26,  diarrhea; 
looked  as  if  he  were  about  to  have  a  new  hallucinatory 
episode.  This,  however,  did  not  come  about  until  December 
I,  when  he  heard  cannonading  and  knew  the  regiment  was 
near.  Next  day  he  had  forgotten  the  cannonading.  Decem- 
ber 14,  the  patient  had  become  entirely  tranquil  and  lucid 
and  was  able  to  give  his  entire  history.  December  16  and 
17  he  was  given  a  systematic  neurological  examination,  which 
showed  on  the  left  side  complete  anesthesia,  hyperesthesia 
to  pressure,  thermanesthesia,  analgesia,  loss  of  bone,  tendon, 
and  muscle  sensation.  Vision  was  diminished  more  on  the 
right  side  than  on  the  left,  and  the  visual  fields  on  this  side 
were  more  contracted.  During  examination,  the  fields  be- 
came still  more  tubular.  There  was  complete  deafness, 
anosmia,  and  ageusia  on  the  left  side.  On  the  right  side 
there  was  a  slight  diminution  of  hearing.     The  pharyngeal 


5i8  shell-shock:  nature  and  causes 

reflex  was  abolished;  the  cremasteric  reflex  was  somewhat 
less  on  the  left  than  the  right;  and  the  defensor  reflexes  of 
the  left  leg  were  less  marked  than  those  of  the  right.  There 
was  no  clonus  or  Babinski.  The  dynamometer  grasp  on  the 
right  was  37;  on  the  left  18;  and  on  this  side  there  was  a 
limitation  of  voluntary  movements. 


SHELL-SHOCK:  NATURE  AND  CAUSES         519 


ETIOLOGY  OF   SHELL-SHOCK 

WOUNDS  14  of  150 

PHYSICAL 
Exhaustion  From  Exposure,  Hardship    (all  neuropaths)      3  of  142 
Concussion  52  of  142 

CHEMICAL  —  Shell  Gas  3  of  150 

PSYCHIC 
Gradual  Exhaustion,  Predisposing     (43  neuropaths)      51  of  132 
Same,  Acting  Per  Se     (patients  chiefly  neuropaths) 
Sudden  Shock 

Horrible  Sights  5^  of  142 

Losses  of  Companions 

Fright  Near  Explosion  (one  neuropath) 

Sounds  (a  few  neuropaths) 

RELAPSES  (41  of  150  observed,  three-quarters  neuropaths) 

After  Wiltshire 


Chart  id 


Che  non  e  impresa  da  pigliare  a  gabbo 
descriver  fondo  a  tutto  I'universo, 
ne  da  lingua  che  chiami  mamma  e  babbo. 

For  to  describe  the  bottom  of  all  the  universe 
is  not  an  enterprise  for  being  taken  up  in  sport, 
nor  for  a  tongue  that  cries  mamma  and  papa. 

Inferno,  Canto  xxxii,  7-9. 


520 


C.     THE   DIAGNOSIS  OF  SHELL-SHOCK 

In  the  course  of  our  study  of  psychoses  incidental  in  the 
war  (Section  A)  and  especially  of  Shell-shock's  nature  and 
causes  (Section  B),  we  have  naturally  met  most  if  not  all  of 
the  major  diagnostic  difficulties.  In  the  present  Section  we 
shall  study  cases  for  the  light  they  may  throw  on  the  more 
technical  troubles  of  the  diagnostician.  Who  would  d  priori 
have  felt  that  such  diseases  as  tetanus,  rabies,  malaria,  would 
produce  practical  difficulties  in  clinical  diagnosis  in  the  field 
of  Shell-shock? 

Mayhap  there  was  no  need  to  emphasize  further  the  values 
of  lumbar  puncture  fluid  examination.  Yet  the  admixture  of 
"functional  "  and  "organic  "  symptoms  in  numerous  puzzling 
cases  can  hardly  be  over-emphasized. 

But  the  interpolation,  through  the  ingenious  inquiries  of 
Babinski,  of  a  new  or  but  vaguely  suspected  series  of  "re- 
flex" ("physiopathic  ")  troubles  between  the  organic  neuro- 
pathic disorders  on  the  one  hand  and  the  hysterical  psy- 
chopathic disorders  on  the  other  —  the  result  of  these 
observations,  sampled  only  in  Section  B,  is  given  more  in 
detail  in  the  present  Section.  What  a  split  in  therapeutic 
method  a  recognition  of  this  new  group  of  "physiopathic  " 
disorders  might  entail  is  seen  also  in  further  cases  in  the 
Section  that  follows  this  (Section  D  on  Treatment  and 
Results) . 

A  number  of  simulation  cases  has  been  added. 


52 1 


522  THE   DIAGNOSIS   OF    SHELL-SHOCK 


ETIOLOGICAL    GROUPING    OF    WAR 
PSYCHONEUROSES 

I.   NEUROSO-ORGANIC  ASSOCIATION  (no  causal  nexus) 
II.   REFLEX  NEUROSES  (lesion  disproportionately  slight  by 

COMPARISON   with   PSYCHONEUROSIS) 

III.  NEUROSO-SOMATIC  ASSOCIATION    (Trench    Foot,  Neu- 

ritis,  Radiculitis) 

IV.  FATIGUE  OR  EMOTIONAL  PSYCHONEUROSES  (consider 

effects  of  psychic  contagion,  education) 

V.   PSYCHONEUROSES  ON  ANTEBELLUM   BASIS 

After  Grasset 


Chart  ii 


THE   DIAGNOSIS    OF   SHELL-SHOCK  523 


WAR    PSYCHONEUROSES 

SYMPTOMATIC    GROUPS 

I.   EMOTIONAL  (Hyper-   Hypo-    Para-) 

II.   CONFUSIONAL   (Attention  and  Memory  Disorder, 
Dream  States;  Deliria) 

III.  CONVULSIVE  AND  PITHIATIC   (Hysterical) 

IV.  NEURASTHENIC  AND   PSYCHASTHENIC 

V.   SENSITIVOMOTOR  AND   SENSORIMOTOR  — e.g.,  Limited 
Paralyses,  Contractures,  Deaf-mutism 

VI.   COMPLEX 

VII.   PHYSIOPATHIC   (Babinski) 

After  Grasset 


Chart  12 


524  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Value  of  lumbar  puncture. 


Case  371.     (SouQUES  and  Donnet,  October,  1915.) 

A  colonial  soldier  arrived  at  Paul-Brousse  Hospital  with 
a  hospital  ticket  showing  that  ten  days  before  he  had  had 
commotio  cerebri.  He  was  dull,  had  a  fixed  stare,  held  his 
head  in  his  hands,  was  disoriented  for  time  and  place,  and 
had  lost  memory  for  everything  that  had  happened  for 
eighteen  months.  There  was  no  sign  of  wound.  There  was 
no  motor  disorder  save  that  walking  was  a  bit  slow  and 
uncertain.  Perhaps  the  right  knee-jerk  was  stronger  than 
the  left.  Percussion  of  the  right  Achilles  tendon  produced 
tremor.  The  plantar  reflexes  were  flexor  on  both  sides; 
flexion  lasted  longer  right  than  left.  The  cremasteric  and 
abdominal  reflexes  were  a  little  weaker  on  the  right.  Arm 
reflexes  were  lively.  Sensations  proved  normal.  Complaint 
of  headache,  frontal  and  vertical. 

Lumbar  puncture  October  7,  that  is,  on  the  thirteenth 
day  after  the  shell-shock,  yielded  a  transparent,  slightly 
greenish  fluid,  with  92  cells  per  cm.  (lymphocytes  with  one 
or  two  large  mononuclear  cells  and  a  few  sometimes  degen- 
erated endothelial  cells)  and  hyperalbuminosis. 

October  9,  the  clouding  of  consciousness  was  less  marked. 
The  headaches  and  amnesia  were  constantly  complained  of; 
the  reflexes  were  normal.  October  12,  there  was  less  head- 
ache. October  25,  another  lumbar  puncture  showed  but  14 
or  15  lymphocytes  per  cm.  and  hyperalbuminosis.  There 
was  now  no  longer  any  clouding  of  consciousness.  The 
amnesia,  retrograde  and  anterograde  back  to  May  9,  1914 
(date  of  his  daughter's  birth),  and  up  to  September  25,  191 5, 
persisted.  The  man  did  not  remember  the  declaration  of 
war,  or  the  mobilization,  or  his  regiment,  and  the  like. 
Meantime,  the  man's  judgment  and  reasoning  powers  were 
normal. 

If  there  had  been  no  early  spinal  fluid  examination  of  this 
patient,  he  might  well  have  been  considered  an  hysteric  or 
even  a  simulator. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  525 


Meningeal  and  intraspinal  hemorrhage :  Lumbar 
puncture. 


Case  372.     (GuiLLAiN,  May,  1915.) 

A  gunner  from  Morocco,  who  lost  consciousness  for  an 
hour  March  28,  19 15,  upon  the  explosion  of  a  large- calibre 
shell  in  his  trench,  was  carried  to  the  ambulance.  He 
complained  of  headache  and  generalized  pains.  His  status 
was  scarcely  modified  during  five  weeks,  and  a  generalized 
contracture  of  the  body  developed  whenever  movements 
were  attempted.  In  horizontal  decubitus,  the  muscles  of  the 
limbs  and  neck  were  of  a  normal  tonicity,  but  the  head  went 
into  hyperfiexion  if  the  patient  was  asked  to  sit.  The  eyes 
turned  upward,  and  Kernig's  sign  developed.  The  patient 
could  walk  only  with  short  steps,  with  legs  apart  and  arms 
held  away  from  the  body,  the  head  in  a  sort  of  tetanoid 
dorsal  hyperfiexion.  There  was  a  right-sided  hemiparesis 
with  trepidation  and  the  Babinski  sign. 

Lumbar  puncture  assured  the  diagnosis  of  something 
organic.  The  fluid  contained  blood  cells  and  a  marked 
lymphocytosis.  The  symptoms  evidently  depended  upon 
hemorrhages  in  the  meninges  and  the  nervous  system,  affect- 
ing particularly  the  right  pyramidal  tract. 

Re  hypothesis  of  organic  changes  in  hysterical  cases, 
Roussy  and  Lhermitte  remark  in  comment  upon  albumi- 
nosis  in  the  cerebrospinal  fluid  that  the  albumin  is  perhaps 
due  (in  cases  of  camptocormia)  to  the  effect  upon  venous  and 
lymphatic  circulation  of  the  spinal  curvature.  It  wasSicard's 
claim  that  camptocormia,  or  bent  back,  was  due  possibly  to 
anatomical  changes  in  the  spinal  column,  that  is,  that  camp- 
tocormia was  in  one  sense  a  spondylitis.  In  other  cases  the 
camptocormia  might  be  due  to  a  ligamentous  or  muscular 
change;  that  is,  to  a  syndesmitis  or  a  psoitis.  His  idea  was 
that  the  curvature  was  in  a  sense  antalgic;  that  is,  a  re- 
sponse having  the  purpose  of  avoiding  pain. 


526  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Slight  hyperalbuminosis. 


Case  373.     (Ravaut,  August,  1915.) 

A  farmer,  32,  in  the  66th  Infantry,  was  lying  in  a  dug-out 
March  5,  191 5,  when  a  bomb  threw  him  on  the  ground 
and  covered  him  with  earth.  He  was  picked  up  uncon- 
scious, and  remained  so  for  an  hour.  In  the  ambulance 
it  was  found  that  he  could  hardly  stand,  could  not  speak, 
and  appeared  to  be  completely  confused.  There  was  no  sign 
of  wound.  The  next  day  he  recovered  consciousness  and 
complained  of  a  violent  headache.  He  was  completely  deaf 
in  the  left  ear,  and  vision  was  also  a  little  impaired  on  that 
side.  The  puncture  fluid  was  clear,  and  there  was  a  very 
slight  excess  of  albumin  by  the  heat  test.  The  next  day  the 
headache  had  entirely  disappeared,  the  left  ear  was  abso- 
lutely deaf,  but  the  patient  complained  of  buzzing.  Lumbar 
puncture  the  following  day  showed  a  normal  amount  of 
albumin. 

March  16  the  patient  was  evacuated  to  the  rear  presenting 
no  abnormal  symptom  except  deafness. 

Re  the  spinal  fluid,  Armstrong-Jones  considers  that  a 
shock  directly  sustained  by  the  spinal  apparatus  through 
sudden  impact  to  the  surrounding  cerebrospinal  fluid,  ought 
to  be  felt  more  by  the  anterior  horn  cells  than  by  the  spinal 
root  ganglia,  since  the  latter  are  shielded  by  the  sheath  in 
the  intervertebral  spaces.  Motor  symptoms  would,  natur- 
ally, then  be  more  frequent  than  sensory  symptoms.  He 
also  believes  that  the  controlling  neurones  in  the  intermedio- 
lateral  tracts  that  have  to  do  with  the  sympathetic  system, 
would  be  affected  just  as  anterior  horn  cells  are.  Accordingly, 
the  dilated  pupils,  rapid  heart,  dyspnoea,  and  a  variety  of 
precordial  pains  and  disorder  of  the  viscera  would  ensue. 
The  jar  would  thus  be  communicated  to  the  neuronic  cells 
of  origin  of  two  types:  spinomuscular  and  preganglionic, 
leaving  the  gangliospinal  neurones  relatively  intact. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  527 


Paraplegia,  organic:   Lumbar  puncture. 


Case  374.     (JouBERT,  October,  1915.) 

A  gunner,  23,  was  thrown  to  the  ground,  according  to  his 
story,  by  the  explosion  of  a  large-caHbre  shell,  at  eight  o'clock 
in  the  morning  of  September  10,  19 14.  He  could  not  get  up 
but  thought  he  had  not  lost  consciousness.  September  13, 
he  arrived  at  hospital,  looking  like  a  man  with  dorso-lumbar 
fracture  of  the  spine.  There  was,  however,  no  external  in- 
jury. There  was  a  marked  paresis  of  the  right  upper  extrem- 
ity, with  diminished  sensibility,  weakened  reflexes,  numbness, 
formication.  The  right  lower  extremity  was  subject  to  com- 
plete flaccid  paralysis,  with  lost  reflexes,  and  anesthesia  in  all 
respects  reached  to  the  belt  level,  and  stopped  sharply  at  the 
median  line  of  the  abdomen.  The  left  leg,  also,  was  paretic 
but  the  muscles  could  be  contracted  weakly;  the  knee-jerk 
was  exaggerated;  there  was  a  tendency  to  epileptoid  trepi- 
dation, and  the  sensations  were  only  slightly  diminished. 
There  was  a  Babinski  reflex  on  the  right  side;  the  abdominal 
reflex  was  absent  on  the  left  side;  both  cremasteric  reflexes 
were  present.  The  feet  at  times  gave  formication.  Rectal, 
bladder,  and  sphincter  paralysis.  Dark  albuminous  urine, 
with  a  few  blood  cells,  was  obtained  on  catheterization. 
There  was  an  early  sacral  decubitus;  consciousness  was 
somewhat  clouded.  The  man  made  no  requests  except  for 
something  to  drink,  and  seemed  apathetic. 

Lumbar  puncture,  September  14,  yielded  hemorrhagic  fluid. 
Three  days  later,  the  upper  extremity  regained  its  powers 
and  sensations,  but  the  paraplegia  had  become  complete, 
with  abolition  of  reflexes  on  both  sides,  and  absolute  anes- 
thesia. The  feet  yielded  formication  at  times,  however. 
Sacral  decubitus  increased  and  healed  not.  The  tempera- 
ture varied  between  38  and  39.  The  patient  died  September 
24,  in  coma,  with  anuria  and  Cheyne-Stokes  breathing. 


528  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Gunshot  wound  of  spinal  column;  no  penetration 
or  injury  of  dura  mater :  At  first  quadriplegia ;  later 
cerebellospasmodic  type   of   disorder. 


Case  375.     (Claude  and  Lhermitte,  July,  1917.) 

A  soldier,  22,  sustained  a  gunshot  wound  in  the  neck 
about  the  level  of  the  fourth  cervical  vertebra.  He  im- 
mediately became  quadriplegic.  He  recovered  arm  motion  In 
two  months  and  some  weeks  later  ability  to  stand  and  walk. 

Three  months  after  the  injury,  station  was  difficult,  better 
on  a  broad  base.  Rombergism,  even  with  eyes  open.  Cere- 
bellospasmodic gait.  There  was  no  weakness  of  leg  muscles, 
but  there  was  a  certain  degree  of  weakness  of  the  upper  ex- 
tremities, especially  in  finger  flexion.  There  was  hypertonia 
of  the  muscles  of  all  the  extremities  and  the  hands  showed 
the  signs  of  Raimiste,  of  Klippel  and  Weil,  and  of  Dejerine. 
Static  equilibrium  was  preserved  to  the  will,  but  the  kinetic 
balance  was  affected,  and  as  much  in  the  upper  as  in  the 
lower  extremities.  Ataxia,  tremors,  dysmetria,  adiadocho- 
kinesia,  and  disorder  of  combined  movements  in  thigh  and 
trunk  flexion  were  all  in  evidence.  Meantime,  there  was  no 
disorder  of  sensation  w^hatever  except  that  the  ulnar  border 
of  the  right  hand  showed  a  hypobaresthesia,  and  there  was  a 
disturbance  of  tactile  discrimination  and  absolute  astereog- 
nosis  in  the  hands.  The  deep  reflexes  were  everywhere  in- 
creased, and  ankle  and  patellar  clonus  were  easy  to  excite, 
especially  on  the  right  side.  Bilateral  defense  reflexes.  Bi- 
lateral Babinski  sign.  The  hypertonia  and  ataxia  ebbed 
away  during  the  following  three  months.  Walking  became 
normal,  and  there  was  little  sign  of  difficulty  except  astereog- 
nosis  of  both  hands,  combined  with  slight  disturbance  of 
deep  sensibility  and  poor  response  to  compass  test  in  palm. 

We  here  deal  with  a  case  of  spinal  column  injury  without 
injury  to  the  dura  mater.  This  cerebellospasmodic  form  of 
the  superior  cervical  type  of  spinal  concussion  is  less  frequent 
than  a  quadriplegic  form  with  Brown-Sequard  syndrome.  It 
is  striking  that  both  types  of  concussion  may  recover. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  529 


Spinal  column  trauma,  with  local  signs :  Later, 
hysterical  anesthesia  and  contracture  of  back  mus- 
cles homolateral  with  the  trauma. 


Case  376.     (Oppenheim,  July,   1915.) 

A  musketeer,  wounded  August  20,  1914,  by  a  shell  splinter 
in  right  side  of  vertebral  column,  fell  unconscious,  but  was 
able  afterward  to  crawl  on  all-fours  out  of  the  firing  line. 
Severe  vomiting  and  epistaxis  followed.  August  23,  there 
was  pain  in  the  small  of  the  back;  the  last  two  ribs  were 
painful  on  right  side;  and  the  muscles  were  slightly  swollen 
up  to  the  iliac  crest.  August  30,  a  slight  rise  of  tempera- 
ture (at  first  It  had  been  above  38)  still  persisted,  but  the 
muscular  swelling  was  diminished.  Treatment  by  aspirin 
and  baths.  No  further  rise  of  temperature  after  early  in 
September. 

On  October  9,  patient  was  permitted  to  get  up,  whereupon 
he  showed  a  peculiar  curved  attitude  of  the  body,  reduced 
almost  completely  by  passive  straightening.  Swelling  of  the 
longitudinal  muscles.  Radiograph  negative,  except  that  one 
picture  showed  a  change  in  left  twelfth  rib,  near  the  trans- 
verse process.     Pains  in  left  lumbar  region. 

November  19,  on  examination,  pulse  112.  November  23, 
after  massage,  vomiting.     Temporary  use  of  plaster  corset. 

On  admission  to  the  nerve  hospital  December  22,  the  mus- 
keteer was  unable  to  extend  the  trunk,  and  the  long  muscles 
of  the  back  were  on  the  stretch,  often  as  hard  as  wood, 
especially  those  of  the  left  (longissimus  dorsi).  Patient  lay 
on  right  half  of  pelvis.  Hemianesthesia  and  hemianalgesia, 
left  side.  Tachycardia.  Formerly  the  patient  had  done 
hard  work,  especially  carrying  heavy  bags.  He  declined  to 
be  examined  under  general  anesthesia.  He  seemed  to  be 
of  unreliable  character,  and  his  trouble  did  not  prevent  him 
from  returning  from  leave  of  absence,  on  one  occasion,  drunk. 


530  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Mine  explosion:  Combined  hysterical  and  lesional 
effects. 


Case  377.     (DupoUY,  September,  1915.) 

A  lieutenant,  23,  was  in  a  mine  explosion  June  23,  coming 
out  in  complete  torpor,  with  mutism  and  retention  of  urine. 
He  was  brought  to  hospital  June  26,  with  jactitation,  irreg- 
ular pulse,  markedly  exaggerated  tendon  reflexes,  absent  skin 
reflexes,  sluggish,  dilated  pupils,  especially  right,  and  general 
anesthesia.  The  spinal  fluid  contained  an  excess  of  albumin, 
altered  blood  cells  and  many  lymphocytes. 

Several  hours  after  puncture  he  suddenly  demanded  where 
he  was,  thought  it  was  the  year  1911  when  he  was  in  the 
Dragoons,  talked  about  his  camp,  and  was  confused,  irritable 
and  stereotyped  in  questions.  There  was  no  verbal  amnesia. 
Speech  was  hesitant,  explosive  and  scanning,  suggestive  of 
multiple  sclerosis.  Next  day  there  was  still  retrograde 
amnesia.  He  clung  to  the  belief  that  it  was  July,  1911, 
and  asked  wearisome,  stereotyped  questions.  The  words, 
"German  house  "  caused  a  jactitation,  stiffening  and  relapse 
into  a  second  etat,  out  of  which  he  came  with  hiccoughs  and 
sighs,  and  amnestic  for  this  conversation.  There  was  general 
hypesthesia  and  muscular  weakness  especially  of  legs.  The 
reflexes  were  as  before. 

The  morning  of  June  28,  he  heard  the  hum  of  an  airplane, 
whereupon  his  memory  returned.  It  seems  that  he  had  him- 
self once  ascended.  The  memory  gap  was  now  limited  to  the 
time  immediately  preceding  the  mine  explosion  and  the  days 
following,  up  to  the  time  of  hearing  the  airplane.  He  told 
about  his  military  life  and  also  about  incidents  immediately 
preceding  his  blowing  up.  He  complained  of  malaise  and  of 
pains  in  the  vertebral  column  and  limbs. 

There  was  a  quadrlparesis,  more  marked,  however,  on  the 
left;  walking  with  falls  to  the  left;  astasia  with  left  foot; 
double  facial  paresis;  inability  to  whistle  and  to  close  eyes 
completely;  intestinal  and  bladder  paralysis;  nocturnal 
emissions  non-pleasurable;   partial  anesthesia  of  right  leg,  of 


THE   DIAGNOSIS   OF   SHELL-SHOCK  53 1 

arm  and  of  hand,  with  hyperesthesia  of  thigh,  of  forearm  and 
of  the  posterior  aspect  of  the  upper  arm;  anesthesia  of  the 
left  side,  including  thorax  and  abdomen,  excepting  that  the 
arm  was  hypesthetic  only.  Face  hyperesthetic.  Com- 
plete anesthesia  of  nipple  and  testis;  hypesthesia  of  neck; 
anesthesia  of  tongue,  nose  and  vertex;  plantar,  cremasteric, 
abdominal  reflexes  absent;  exaggerated  tendon  reflexes; 
pupil  reflexes  normal ;  painful  heat  flashes  and  profuse  sweat- 
ing on  the  slightest  movement;  vertigo  and  tendencies  to 
syncope  after  effort;  explosive,  scanning  speech;  inter- 
mittent convulsive  movements  of  the  arms.  Palpation  and 
X-ray  show  separation  of  the  spinous  processes  of  the  third 
cervical  vertebra. 

Improvement  was  marked  and  progressive  in  motor,  sen- 
sory and  reflex  fields.  At  the  time  of  report  three  months 
later,  there  was  a  definite  paresis  of  the  left  leg,  with  anes- 
thesia and  absent  plantar  reflexes,  and  slight  paresis  of  the 
orbicularis  palpebrarum,  scanning  speech  and  syncopal  tend- 
encies. Here,  then,  due  to  diffuse,  non-systematic  lesions, 
with  superadded  hysterical  manifestations,  were  probably 
some  effects  of  a  permanent  nature  due  to  destructive 
processes. 

Re  combination  of  functional  and  lesional  effects,  Sollier 
and  Chartier  state  that  in  Shell-shock  hysteria,  physical 
causes  and  conditions  are  the  chief  factors;  that  in  the  so- 
called  hystero-traumatism  of  Charcot,  the  psychic  and 
physical  factors  are  of  virtually  equal  importance,  and  that 
in  ordinary  cases  of  hysteria,  the  psychic  is  the  chief  genetic 
factor. 


532  THE   DIAGNOSIS    OF    SHELL-SHOCK 


Shell    explosion:    Hysterical    and    organic    symp- 
toms. 


Case  378.     (Hurst,  1917.) 

A  champion  heavy-weight  boxer,  29,  was  unconscious  for 
two  days  after  being  knocked  over  by  the  explosion  of  a  shell 
in  December,  1914.  He  found  at  first  that  he  could  not 
move  the  right  arm  or  left  leg;  and  after  power  had  returned 
to  the  limbs,  he  had  forcible  involuntary  movements  in  the 
left  leg  whenever  he  tried  to  stand.  Examined,  April  i, 
191 5,  he  answered  questions  slowly  and  with  slow  words; 
the  right  arm  was  weak.  When  the  left  hand  was  clenched, 
an  associated  movement  took  place  in  the  right  hand,  but  not 
vice  versa.  There  was,  however,  no  diminution  in  the  girth 
of  the  muscles.  The  man  was  unable  to  localize  light  tactile 
stimuli  accurately.  Movements  of  the  left  leg  were  some- 
what weak,  the  left  knee-jerk  was  slightly  brisker  than  the 
right;  ankle  clonus  could  be  obtained  on  the  left  side  and 
Babinski  second  sign  (paralyzed  leg  rising  higher  than  the 
normal  leg  in  combined  flexion  of  thigh  and  pelvis).  When 
the  man  tried  to  walk,  the  left  leg  moved  rapidly  from  side  to 
side  round  the  point  of  contact  of  the  toes.  When  the  right 
leg  moved  forward,  the  left  dragged  behind  in  irregular 
movement. 

Every  eflfort  to  cure  the  patient  by  means  of  suggestion 
during  hospital  care  for  a  month  entirely  failed.  Although 
the  man  was  easily  hypnotizable,  he  could  not  be  made  to 
move  his  leg  under  the  deepest  hypnosis.  The  first  whiff  of 
ether  hypnotized  him,  so  that  the  method  of  etherization 
could  not  be  used  in  the  endeavor  to  control  the  leg  move- 
ments. Over  a  year  later,  July,  19 16,  the  patient  had  greatly 
improved  mentally  but  was  otherwise  in  precisely  the  con- 
dition that  is  above  described. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  533 


Gunshot  wound  of  buttocks  with  injury  to  cauda 
equina:  Urinary  disturbance;  decubitus;  anesthe- 
sia. Superimposed  paraplegia,  regarded  as  func- 
tional and  cured  by  psychotherapy. 


Case  379.     (Oppenheim,  July,  191 5.) 

A  German  grenadier,  October  11,  19 14,  was  wounded  In 
the  left  buttock  by  a  missile  that  passed  out  through  the 
right  buttock.  Pains  in  the  abdomen  and  legs  followed. 
The  man  had  to  be  catheterized  on  the  battle-field. 

October  23,  he  suddenly  fell  down  with  total  paralysis  of 
both  legs. 

November  3,  numerous  small  furuncles  appeared  on  the 
buttocks,  and  bedsores  developed.  The  patient  lay  helpless 
in  bed,  was  unable  to  sit  up  without  support,  or  to  turn  from 
one  side  to  the  other,  and  had  areas  of  anesthesia. 

During  November  and  December,  there  was  persistent 
high  temperature,  between  38  and  40;  but  January  3  the 
temperature  stood  at  36.6. 

January  7  the  patient  was  admitted  to  a  nerve  hospital. 
At  this  time  he  was  able  to  pass  urine  unaided,  though  with 
tenesmus  and  pain,  sometimes  nausea  and  a  tendency  to 
vomit.  He  complained  of  pain  In  the  back  and  pelvic  region; 
the  legs  lay  as  if  paralyzed.  No  active  movement  whatever 
was  performed,  There  was  a  marked  Increase  of  tendon 
reflexes  (even  Including  the  seml-membranosus) .  The  mus- 
cles were  relaxed  through  disuse  but  there  was  no  atrophy. 
The  patient  moved  his  legs  about  with  his  hands.  Sensi- 
bility was  preserved  except  In  the  region  of  the  pubis.  The 
plantar  reflexes  were  absent.     Electrical  reactions  normal. 

The  diagnosis  w^as  functional  paralysis  of  the  legs  (previous 
gunshot  Injury  of  cauda  equina). 

Treatment  with  psychotherapy  met  with  prompt  results; 
within  a  few  days,  the  patient  learned  to  move  his  legs  and 
to  walk  with  support,  though  making  enormous  efforts  which 
threw  the  pulse  up  to  about  160  and  made  the  face  congested. 
The  bladder  disturbance  and  the  sacral  anesthesia  persisted. 


534  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Spinal  concussion  with  spinal  cord  lesion:   Ther- 
manesthesia  and  analgesia  of  right  leg  and  side. 


Case  380.     (Buzzard,  December,  191 6.) 

An  officer  was  hit  in  the  back  by  a  shrapnel  fragment, 
fell  paralyzed,  but  after  a  few  minutes  was  able  to  walk  more 
than  a  mile  to  the  dressing  station.  Eventually  arriving  in 
London,  he  had  nothing  to  complain  of  except  the  wound, 
as  the  foreign  body  had  been  removed  in  France.  The 
wound  healed  and  the  patient  went  to  a  convalescent  home. 

However,  when  taking  a  bath  he  could  not  feel  the  tem- 
perature of  the  water  with  the  right  leg.  Muscular  power 
was  perfect;  reflexes  normal;  but  the  heat,  cold  and  pain 
sense  was  lacking  in  the  right  leg  and  the  right  side  of  the 
body  from  the  seventh  costal  cartilage  downwards. 


One    may  make   a  wrong    diagnosis    of    **  Shell- 
shock." 


Case  381.     (Buzzard,  December,  1916.) 

In  August,  1915,  an  officer  was  blown  many  yards  by  a 
shell,  lay  unconscious  a  while,  could  find  no  bruises,  and  car- 
ried on  for  twenty-four  hours.  Then,  finding  legs  unreliable,. 
he  reported  sick  and  was  sent  home  as  "Shell-shock."  He 
remained  "Shell-shock"  until  February,  191 6,  then  being  able 
to  walk  five  or  six  miles  on  smooth  ground.  Going  downstairs 
he  took  the  step  with  left  foot  rather  than  with  right,  and  the 
right  was  apt  to  turn  in.  The  sense  of  position  and  move- 
ment in  regard  to  the  right  foot  proved  to  be  faulty.  He 
could  not  balance  himself  on  the  right  foot,  nor  could  he 
appreciate  tuning  fork  vibrations  as  well  on  this  foot  as  on 
the  other. 

An  X-ray  examination  showed  a  slight  fracture,  without 
deformity,  in  the  left  post-RolandIc  region  near  the  median 
line.  His  helmet  had  been  bashed  in  at  this  point,  and 
the  bruised  brain  yielded  symptoms  even  eight  months  later. 


THE   DIAGNOSIS   OF    SHELL-SHOCK  535 


Retention  of  urine  after  shell-shock. 


Case  382.     (GuiLLAiN  and  Barre,  November,  191 7.) 

An  infantryman  underwent  shell-shock  December  19,  1915, 
from  the  explosion  of  a  torpedo  nearby.  He  arrived  at  the 
ambulance,  unable  to  speak,  and  next  day  had  a  confuslonal 
crisis  of  convulsions  with  contractures.  He  had  not  urinated 
since  the  accident,  and  two  liters  of  clear  urine  were  with- 
drawn by  catheter;  after  which,  the  patient  rested  quietly 
and  gradually  regained  consciousness.  He  was  catheterized 
again  in  the  evening  and  clear  urine  withdrawn.  He  re- 
mained unable  to  urinate  spontaneously  until  December  25, 
and  was  catheterized  accordingly. 

There  was  no  motor,  sensory,  or  reflex  disorder  in  this 
patient.  Lumbar  puncture  yielded  a  normal  fluid;  the 
pupils  were  normal,  and  the  only  appearance  was  that  of  a 
marked  asthenia. 

Three  months  after  his  shell-shock,  in  March,  191 6,  the 
soldier  was  once  more  examined  and  still  complained  of 
headache,  weakness,  and  inability  to  walk  more  than  four  or 
five  hundred  meters  without  a  certain  trembling  of  the  legs. 
The  reflexes  remained  normal  and  no  further  bladder  trouble 
had  supervened. 

Re  anuria,  Babinski  remarks  that,  in  days  of  yore,  hysteria 
was  supposed  to  be  able  to  produce  anuria  as  well  as  albumi- 
nuria, and  even  such  organic  changes  as  vesicles  of  the  skin, 
ulceration,  hemorrhages  in  the  skin  or  of  the  viscera,  fever, 
and  even  gangrene.  He  remarks  that  of  late  years  no  single 
identifiable  case  of  this  sort  proved  to  be  hysterical,  has  been 
reported.  This  is  aside,  of  course,  from  such  superficial  and 
quickly  passing  vasomotor  disorders  as  erythema  and  derma- 
tographia.  Anuria  and  albuminuria  have  consequently 
passed  from  the  textbooks  on  hysteria,  just  as  Babinski 
believes  that  hysterical  edema  and  hysterical  exaggeration 
of  the  reflexes  are  bound  to  pass.  Hysteria  cannot  imitate 
everything;  it  cannot  reproduce  the  characteristic  phe- 
nomena of  organic  paralysis. 


536  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Retention  of  urine  after  shell-shock. 


Case  383.  (GuiLLAiN  and  Barre,  November  191 7.) 
An  infantryman,  27,  underwent  shell-shock  August  16, 
191 6,  at  four  o'clock,  from  the  nearby  explosion  of  a  big 
shell.  He  lost  consciousness  for  a  period  of  ten  minutes,  was 
sent  to  the  regimental  aid  post,  and  twelve  hours  later 
brought  to  a  hospital  center,  in  a  state  of  profound  muscular 
weakness.  He  could  not  walk  although  he  could  make  every 
movement  of  the  legs.  There  was  a  marked  diffuse  cuta- 
neous hyperesthesia.  The  reflexes  were  normal;  the  pupils 
were  unequal,  the  right  myotic.  The  lumbar  puncture 
yielded  a  clear  fluid  under  normal  pressure,  but  with  an  ex- 
cess of  albumin.  For  three  days,  retention  of  urine  was 
absolute,  requiring  the  catheter.  There  was  neither  sugar 
nor  albumin  in  the  urine  withdrawn.  On  the  fourth  day  he 
was  able  to  urinate  spontaneously;  the  asthenia  and  other 
symptoms  had  disappeared  in  two  or  three  weeks. 


Incontinence  of  urine  after  shell-shock  and  burial. 


Case  384.  (GuiLLAiN  and  Barre,  November,  191 7.) 
An  infantryman  was  subject  to  shell  explosion  and  burial 
May  10,  191 7.  He  lost  consciousness  for  a  few  hours  and 
spat  blood  for  two  days.  He  was  carried  to  an  evacuation 
hospital  and  thence  to  the  neurological  center  at  Amiens. 
Incontinence  day  and  night  lasted  from  the  period  of  shock 
up  to  May  29,  when  the  patient  was  transferred  again,  to 
another  hospital.  The  man  had  never,  either  in  childhood 
or  adult  life,  had  incontinence.  He  showed  a  slight  tendency 
to  latero-pulsion  toward  the  left.     Puncture  fluid  normal. 

Gulllain  and  Barre  report  but  12  cases  of  sphincter  dis- 
order following  shell-shock  without  external  wound  among 
hundreds  of  cases,  and  among  12  instances  of  sphincter  dis- 
order there  were  but  three  of  incontinence,  of  which  the 
above  is  one  example.  Incontinence  lasted  longer  in  these 
cases  than  retention.  Gulllain  and  Barr6  are  unable  to 
assign  a  cause  for  the  findings. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  537 


Struck  in  back  by  shell  splinter:    Crural  mono- 
plegia; absence  of  plantar  reflex. 


Case  385.     (Paulian,  February,  191 5.) 

An  infantryman,  20,  was  struck  by  a  shell  fragment  in  the 
small  of  the  back  while  lying  in  the  firing  position,  about 
2  P.M.  August  22,  1914,  at  Eth  in  Belgium.  He  felt  as  if  he 
had  been  struck  by  the  butt  of  a  gun  in  the  lumbar  region. 
He  was  unable  to  get  back  with  his  comrades.  His  sack  had 
been  cut.  He  was  without  ammunition,  and  getting  to  a 
bridge  he  was  able  to  jump  a  distance  of  about  8  meters.  He 
fell  and  fainted.  On  coming  to  himself,  his  left  side  felt  bad 
and  he  could  not  move  his  left  leg.  He  dragged  himself  to 
the  relief  post  w^hich  was  being  bombarded  just  as  he  ar- 
rived, and  he  got  a  bullet  in  the  left  frontal  region. 

He  was  evacuated  to  another  ambulance  and  decided  to 
go  back  to  France.  Supported  by  his  Lieutenant,  he  walked 
all  night  making  about  35  kilometers  on  foot.  He  arrived 
at  Charancy  and  got  by  train  to  Mont-Midi.  On  alighting, 
he  could  not  walk.  He  said  he  was  bent  in  two,  and  shuffled 
on  in  this  position. 

The  "bent-back  "  lasted  about  a  month,  when  he  began  to 
stand  up  again.  He  passed  through  various  hospitals  and 
was  evacuated  to  the  Salpetriere.  He  then  walked  with  the 
left  leg  in  extension  on  the  thigh  and  the  foot  in  external 
rotation.  He  was  hardly  able  to  stand  on  either  foot,  and 
especially  fell  if  he  tried  to  stand  on  the  left  foot.  He  made 
no  resistance  to  passive  movements  of  the  left  lower  extrem- 
ity. The  reflexes  were  normal  except  that  the  left  plantar 
reflex  was  abolished.  On  the  right,  the  plantar  reflex  was 
normal,  and  an  attempt  to  elicit  this  reflex  was  followed  by 
strong  defensive  movements.  There  was  a  tactile,  thermic, 
and  pain  anesthesia  of  the  foot  and  leg  as  far  up  as  the  lower 
third  of  the  thigh.  Above  this  anesthesia,  there  was  a  zone 
of  hypesthesla.  Position  sense  was  also  abolished  In  this  re- 
gion, and  there  was  a  bony  hypesthesla  likewise.  A  slight 
muscular  atrophy  (2  cm.)  affected  the  lower  leg  and  thigh. 


538  THE   DIAGNOSIS   OF   SHELL-SHOCK 

There  were  no  hereditary  or  acquired  features  of  impor- 
tance in  the  case  except  that  there  had  been  at  14  a  chorea  for 
a  year.  In  particular  this  man  appears  not  to  have  been  an 
emotional  person. 

The  point  in  the  case  is  the  abolition  of  the  plantar  reflex 
on  the  left  side,  in  association  with  a  functional  paraplegia 
and  hemianesthesia. 

Re  plantar  reflex  modification  in  hysteria,  Babinski  believes 
that  the  same  law  which  holds  that  hysteria  is  not  in  line  to 
alter  either  the  tendon  reflexes  or  the  pupil  reflexes,  is  true  for 
the  skin  reflexes.  Dejerine  brought  forward  three  cases  which 
appeared  to  him,  however,  to  demonstrate  absolutely  that 
functional  anesthesia  might  abolish  or  greatly  diminish  the 
skin  reactions  of  the  sole  of  the  foot,  that  is,  the  plantar 
reflexes  and  movements  of  defense.  Case  385  was  alleged 
in  support  of  Dejerine,  as  also  were  cases  of  Jeanselme  and 
Huet,  and  of  Solller.  Babinski's  critique  of  Dejerine's  cases 
ran  to  the  effect  that  two  of  them  showed  contractures,  and 
accordingly  were  not  pure  cases  in  which  to  demonstrate 
plantar  reflexes  or  movements  of  defense.  In  the  third  case, 
Babinski  at  a  meeting  of  the  Neurological  Society,  himself 
obtained  definite  flexion  of  the  little  toes  by  stimulating  the 
planta.  According  to  Babinski,  therefore,  Dejerine's  cases, 
far  from  proving  that  hysterical  anesthesia  could  abolish 
the  plantar  cutaneous  reflexes,  proved  that  hysterical  con- 
tracture might  mask  reflex  movements.  Hysterical  contrac- 
ture, therefore,  may  be  as  important  a  factor  to  consider  re 
reflexes  as  voluntary  muscular  contracture  Itself.  As  Ba- 
binski pointed  out,  many  normal  persons  can  keep  the  leg 
immobile  when  the  sole  is  stimulated.  Moreover,  Babinski 
pointed  out,  many  cases  regarded  as  hysterical  were  actu- 
ally cases  of  a  physiopathic  or  reflex  nature  which  had 
actually  undergone  trauma.  It  will  be  noted  that  the  above 
case  of  Paulian  is  just  such  a  case  of  trauma. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  539 


Shell-shock;       unconsciousness:       Crural   mono- 
plegia; sciatica  (neural  changes). 


Case  386.     (SouQUES,  February,  191 5.) 

A  reserve  lieutenant,  September,  1914,  was  blown  up  by  a 
shell  and  lost  consciousness  for  an  hour.  On  coming  to,  he 
felt  pains  in  the  loins,  right  thigh,  knee  and  heel,  and  found 
himself  unable  to  move  the  right  leg  at  all.  Urinary  incon- 
tinence lasted  three  or  four  days.  Violent  pains  lasted  weeks, 
now  and  then  actual  crises  (sleep  only  with  hypnotics). 

The  pains  then  passed  off.  The  flaccid  crural  monoplegia 
lasted.  There  was  a  hydrarthrosis  of  the  right  knee  and  a 
sciatica  (physical  nerv^e  changes?)  and  a  crural  monoplegia 
without  trophic,  electrical,  reflex  or  vesico-rectal  trouble. 
Lumbar  puncture  showed  no  lymphocytes  or  excess  of  al- 
bumin. It  would,  of  course,  be  difficult  to  tell  whether  this 
case  was  h3^steria  or  simulation. 

Re  hysterical  monoplegia,  Babinski  inquires  whether  a 
hysterical  monoplegia  can  automatically  appear  as  a  result 
of  emotion  without  any  intellectual  element  whatever.  Emo- 
tion produces  sweat,  diarrhea  or  erythema,  without  any 
intellectual  intermediate.  Can  emotion  —  that  is,  emo- 
tional shock  — produce  a  monoplegia  in  the  same  way  as 
it  produces  an  erythema?  The  narratives  of  patients  might 
Indicate  that  emotion  can  do  such  things.  But  according  to 
Babinski  there  Is  no  genuine  case  of  monoplegia  or  para- 
plegia directly  produced  by  emotional  shock.  One  must  be 
careful  In  this  discussion  not  to  confuse  emotional  shock  and 
emotion  of  a  gradual  nature.  Babinski  wishes  to  define  emo- 
tion as  a  violent  affective  change  as  a  result  of  a  [sudden 
mental  shock  upsetting  physiologic  or  psychic  balance  dur- 
ing a  usually  brief  period.  As  for  the  more  gradual  affective 
states  or  emotions,  there  Is  obviously  so  much  of  the  imagi- 
native and  intellectual  compounded  therewith,  that  plenty 
of  opportunity  exists  for  the  production  by  suggestion  of 
such  "phenomena  as  monoplegia,  paraplegia,  hemi-anesthesla. 

Re  sciatica,  see  remarks  above  under  Case  329. 


540  THE   DIAGNOSIS   OF    SHELL-SHOCK 


Functional  paraplegia  and   internal  popliteal  neu- 
ritis. 


Case  387.     (RoussY,  February,  1915.) 

A  Zouave  was  taken  out  from  under  a  trench  shelter  beam, 
the  night  of  December  21,  1914,  at  Tracy-le-Mont.  The 
beam  had  fallen  upon  eight  men,  killing  one,  and  striking  the 
Zouave  in  the  hypogastrium.  He  was  pulled  out  two  hours 
later,  unable  to  take  a  step.  He  was  evacuated  on  his  back, 
to  Paris;  stayed  a  month  In  the  hospital  at  Croix- Rouge, 
bedfast.  According  to  the  patient,  he  was  entirely  anes- 
thetic in  the  legs.  He  went  to  Villejuif,  January  22,  with 
the  diagnosis  of  spinal  contusion  and  hemiplegia.  He  could 
then  walk  on  crutches,  leaning  on  the  left  leg.  He  felt  a 
sharp  pain  at  the  level  of  the  spinous  process  of  the  first 
lumbar  vertebra  and  all  along  the  sacrum.  Spontaneous 
movements  of  the  left  leg  were  possible,  but  they  were  slow 
and  weak.  The  hypesthesia  rose  to  the  navel.  There  was  a 
suggestion  of  a  cauda  syndrome.  The  knee-jerks  were  nor- 
mal, but  on  the  left  side  the  Achilles  jerk  was  absent.  There 
was  a  partial  R.  D.  In  the  posterior  muscles  of  the  left  leg. 

The  diagnosis  was  functional  paraplegia  plus  left  Internal 
popliteal  neuritis.  The  crutches  were  removed,  he  was  iso- 
lated, and  given  motor  reeducation.  In  a  week  he  was  able 
to  walk  alone  with  ease. 

Ke  popliteal  nerve  lesions,  Athanassio-Benisty  remarks  that 
the  external  popliteal  nerve  of  the  leg  resembles  pathologi- 
cally the  musculospiral  nerve  of  the  arm,  whereas  the  in- 
ternal popliteal  behaves  like  the  median.  The  musculo- 
spiral nerve  of  the  arm  shows  very  variable  and  usually 
slight  sensory  changes.  The  median  nerve  more  than  any 
other  nerve  in  the  arm  yields  painful  sensations  during  its 
recovery  from  section. 

Ke  differentiation  of  peripheral  neuritis  and  hysterical 
paralysis,  BabinskI  gives  as  signs  peculiar  to  neuritis,  and 
never  found  In  hysterical  paralysis,  the  following:  (a)  dimi- 
nution or  loss  of  bone  and  tendon  reflexes;     (&)   muscular 


THE   DIAGNOSIS   OF   SHELL-SHOCK  54 1 

atrophy  (except  for  slight  amyotrophy  exceptionally  found 
in  hysteria) ;  (c)  the  reaction  of  degeneration  (only  of  value 
after  eight  or  ten  days) ;  {d)  hypotonus ;  {e)  distribution 
characteristic  of  peripheral  motor  sensory  and  trophic 
disorder. 

Re  diagnosis  of  organic  paraplegia  as  against  hysterical 
paraplegia,  the  latter  is  to  be  recognized  chiefly  by  the  ab- 
sence of  the  organic  signs,  as  {a)  alteration  of  tendon  reflexes, 
{b)  the  Babinski  sign  (toe  phenomenon),  (c)  exaggeration  of 
defense  reflexes  (dorsal  flexion  of  foot  on  sharp  pinching  of 
dorsum  of  foot  or  leg),  {d)  muscular  atrophy  with  R.  D., 
{e)  sphincter  disorder,  (/)  skin  changes,  such  as  decubitus. 


542  THE   DIAGNOSIS   OF    SHELL-SHOCK 


Bullet  in  hip :   Local  "  stupor  "  of  leg. 


Case  388.     (Sebileau,  November,  1914.) 

A  Moroccan  sharpshooter,  20,  was  wounded  September 
27,  at  Solssons.  One  bullet  scratched  the  left  thigh.  A 
second  entered  below  the  anterosuperior  iliac  spine  at  least 
6  cm.  outside  the  femoral  artery  and  emerged  above  the 
ischiotrochanteric  line,  2  cm.  above  and  4  cm.  behind  the 
upper  extremity  of  the  great  trochanter,  thus  passing  through 
the  tensor  of  the  fascia  lata  and  without  breaking  a  bone. 

There  was  a  complete  paralysis  of  the  left  leg.  The  man 
had  to  walk  with  a  crutch  and  a  cane,  dragging  the  leg  like  a 
weight.  There  was  no  active  or  passive  movement  of  thigh, 
lower  leg  and  foot  muscles,  except  that  there  was  a  slight 
tendency  to  abduction  of  the  toes,  from  innervation  of  the 
dorsal  interossei  of  the  foot.  The  iliopsoas  was  also  involved, 
as  well  as  the  gluteal  and  pelvic  trochanteric  muscles.  There 
was  a  certain  amount  of  muscular  tone  preserved,  so  that  the 
bony  elements  of  the  skeleton  were  held  together.  The  foot 
did  not  fall  and  the  leg  did  not  elongate,  as  it  might  have  In  a 
case  of  paralysis  of  the  sciatic  nerve.  Electro-diagnosis 
showed  an  early  reaction  of  degeneration  according  to  one 
examiner,  but  Sebileau  believes  that  there  was  no  R.  D. 
There  was  anesthesia  of  a  large  part  of  the  leg,  which  stretched 
over  the  anterior  and  internal  aspects  of  the  thigh,  covered 
the  entire  territory  of  obturator  and  crural  nerves  but  did 
not  stretch  above  the  fold  of  the  groin.  The  region  of  the 
femorocutaneous  nerve  was  slightly  sensitive  and  the  pos- 
terior aspect  of  the  thigh  and  buttock  was  sensitive.  There 
was  a  slight  sensation  on  the  external  aspect  of  the  lower  leg. 
Foot  and  toes  were  entirely  insensitive.  The  anesthesia  was 
for  all  forms  of  common  sensation.  No  vasomotor,  ,thermic 
or  trophic  disorder.  The  reflexes  were  all  abolished,  except 
for  a  tendency  to  cremasteric  reflex.  It  Is  clear  that  these 
conditions  cannot  be  simulated.  Possibly  they  are  hysteric 
and  to  be  explained  on  the  basis  of  a  kind  of  autosuggestion 
or  perhaps,   according  to  Sebileau,   the  local  and  nervous 


THE   DIAGNOSIS   OF   SHELL-SHOCK  543 

apparatus  under  the  mechanical  and  caloric  effects  of  the 
fragment  had  undergone  a  sort  of  local  stupor.  No  large 
nerve  could  have  been  affected  by  the  injury,  according  to 
the  analysis  made  by  Sebileau. 

Re  stupor,  see  Case  253  of  Tinel.  Re  such  local  "stupor" 
it  may  be  noted  that  this  case  was  published  in  1914,  before 
Babinski's  larger  publications  on  reflex  disorders.  As  for 
the  loss  of  cutaneous  reflexes,  Babinski  remarks  that  immer- 
sion in  hot  water  may  cause  the  cutaneous  reflexes  in  the 
so-called  physiopathic  cases  to  reappear  for  a  time.  He 
regards  the  loss  of  cutaneous  reflexes  in  the  physiopathic 
cases  as  due  to  a  circulatory  disturbance,  and  recalls  the 
fact  that  compression  by  an  Esmarch  bandage  can  cause 
the  tendon  reflexes  to  vanish  for  a  time,  and  can  even  cause 
pathologically  excessive  reflexes  to  disappear.  The  cuta- 
neous reflexes  have  also  been  caused  to  disappear  by  com- 
pression. 

According  to  Babinski,  Sebileau's  explanation  that  such 
matters  as  loss  of  reflexes  could  be  explained  by  autosugges- 
tion is  erroneous. 

Re  muscular  hypertonus  in  reflex  cases,  Babinski  remarks 
that  though  it  may  be  very  pronounced,  it  is  as  a  rule  re- 
stricted in  area.  Re  sensory  disorders  in  reflex  cases,  pains 
are  found  (they  were  very  slight  ones  in  the  present  case) ; 
hypesthesia  has  also  been  found  by  Babinski, 


544  THE   DIAGNOSIS   OF    SHELL-SHOCK 


Localized  catalepsy:   Hysterotraumatic. 


Case  389.     (SoLLiER,  January,  191 7.) 

An  invalided  soldier  had  been  suffering  for  a  year  with 
marked  atrophies  and  the  right  knee  in  extension.  There 
had  been  a  bullet  wound  of  the  upper  third  of  the  tibia,  which 
did  not  affect  the  joint.  There  was  a  total  anesthesia,  both 
superficial  and  deep,  which  stopped  sharply  at  the  upper 
part  of  the  thigh.  At  the  time  of  the  very  first  examination, 
this  apparent  ankylosis  was  reduced,  to  the  great  stupefac- 
tion of  the  patient.  There  was,  however,  a  peculiar  phe- 
nomenon in  this  subject.  There  was  a  localized  catalepsy  of 
the  limb,  which  was  able  to  preserve  any  desired  attitude  in 
which  it  was  placed;  and  this  attitude  could  be  indefinitely 
prolonged,  just  as  in  cataleptic  hysterics.  Here,  then,  was  a 
case  of  localized  hystero-traumatism  precisely  imitating  the 
classical  hysteria  of  Charcot  except  for  its  localization. 

Re  hysterotraumatism,  Charcot  developed  ideas  concern- 
ing trauma  and  localized  hysteria  in  1886,  thereby  over- 
throwing the  ideas  of  Erichsen  concerning  the  organic  nature 
of  "railway  spine"  and  "railway  brain"  as  developed  twenty 
years  before.  In  a  case  of  local  trauma  such  as  the  bullet- 
wound  of  Case  388,  Bablnski's  explanation  would  be  that  the 
pain  and  Inhibition  of  movement  resulting  from  the  bullet 
wound  at  the  time  of  Injury,  formed  the  focus  of  a  process  of 
autosuggestion.  According  to  Bablnski's  figure,  the  organic 
factor  acts  as  a  hait  for  the  hysterical  symptoms.  Accord- 
ing to  the  Salpetriere  experience,  hysteria  Is  Incapable  of 
producing  a  real  superficial  and  deep  anesthesia  such  as  Is 
mentioned  for  this  case.  For  example,  no  hysterical  patient 
in  the  Charcot  clinic,  according  to  Sicard,  could  undergo  a 
scalpel  operation  without  some  general  or  local  anesthetic. 
When,  therefore,  a  true  deep  anesthesia  occurs,  ,Sicard's 
conception  would  be  that  the  anesthesia  is  not  a  truly  hysteri- 
cal one  but  belongs  to  the  group  of  physlopathic  phenomena. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  545 


Contracture :   Hysterotraumatic. 


Case  390.     (SoLLiER,  January,  191 7.) 

A  sailor,  41,  got  hygroma  of  the  right  knee  in  191 5,  was 
operated  on  in  July,  returned  to  his  depot  a  month  later,  and 
thence  to  Vizille  Urage  by  reason  of  contracture  in  extension 
of  the  right  leg.  It  was  thought  he  was  simulating  (since 
there  was  no  muscular  atrophy),  and  he  was  sent  to  the 
neurological  center,  where  under  anesthesia  the  joint  was 
found  free.  This  man  developed,  when  the  knee  was  bent, 
extraordinary  cracklings  in  the  joint,  and  he  showed  pain 
unequivocally,  making  a  defensive  movement,  partly  reflex, 
partly  voluntary,  when  the  leg  was  flexed  beyond  a  certain 
point.  There  was  3.5  cm.  atrophy  in  the  thigh,  a  reflex 
atrophy  due  to  the  joint  disorder.  There  were  no  other 
signs  of  hysterotraumatic  contracture. 

According  to  Sollier,  the  diagnosis  of  hysterotraumatic 
contractures  depends  upon:  first,  a  characteristic  special  atti- 
tude of  the  contractured  limb;  secondly,  the  participation  of 
the  antagonists  as  a  group  {global) ;  thirdly,  the  superposition 
of  sensory  disorder  upon  motor  disorder  (Charcot's  law); 
fourthly,  the  segmentary  topography  of  sensory  disorder; 
fifthly,  the  extension  of  the  contractured  joint;  sixthly,  the 
persistence  of  the  contracture  in  the  same  form,  whether  at 
rest  or  in  attempted  movements ;  seventhly,  muscular  rigidity ; 
eighthly,  normal  tendon  reflexes;  ninthly,  normal  electrical 
reactions  (though  R.  D.  Is  hard  to  determine  in  muscles  con- 
tracted to  the  maximum) ;  tenthly,  special  reactions  during 
attempts  to  reduce,  such  as  pains,  and  equal  and  regular 
resistance  to  changed  attitude,  pseudoclonus  in  cases  of  foot 
contracture;  eleventhly,  immediate  reproduction  of  the  con- 
tracture after  reduction  under  chloroform;  twelfthly,  co-ex- 
istence of  various  hysterical  stigmata. 


546  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Crural  monoplegia,  tetanic.     Recovery. 


Case  391.     (RouTiER,  1915.) 

An  ensign  was  wounded  by  a  shell  splinter  in  the  right 
scapular  region  September  25,  19 15.  A  large  hematoma  was 
drawn  off  and  drains  inserted.  Antitetanic  serum  was  given 
24  hours  after  the  trauma.  The  wound  looked  well.  The 
patient  complained  merely  of  the  heaviness  of  his  arm,  and 
after  September  2"],  the  temperature  fell  to  normal.  Mag- 
nesium chloride  solution  was  applied  every  other  day,  and 
progress  was  so  good  that  evacuation  was  ordered. 

However,  October  8,  the  patient  suddenly  began  to  com- 
plain of  a  sharp  pain  in  the  right  thigh,  which  next  day  be- 
came intolerable  and  threw  the  muscles  into  a  slight  con- 
tracture, the  adductors  being  extremely  stiff.  Headache 
developed  in  the  course  of  the  day,  with  slight  stiffness  of 
neck,  exaggeration  of  reflexes  in  the  right  leg,  and  ankle 
clonus.  Temperature:  37.6  morning,  38.5  evening.  The 
patient  was  isolated  and  given  chloral. 

October  10,  paroxysmal  crises  of  pain,  more  marked  stiff 
neck,  and  lumbar  stiffness  appeared,  with  nervousness, 
photophobia,  and  hyperesthesia  to  noise.  The  wound  seemed 
to  be  doing  well.     Chloral  was  given. 

Slight  trismus  developed  October  11.  The  tongue  became 
dry  and  the  patient  drank  little.  The  condition  held  and  the 
same  treatments  were  repeated  up  to  October  15,  when  the 
temperature  fell  and  the  contractures  and  pains  were  dim- 
inished. The  chloral  was  continued.  There  were  still  a  few 
cramps  in  the  neck.  October  22,  however,  the  patient  was 
practically  well. 

We  are  here  dealing  with  an  instance  of  local  tetanus  of 
monoplegic  form,  developing  a  fortnight  after  the  wound 
(there  is  an  early  group  developing,  as  a  rule,  from  the  fifth 
to  the  tenth  day,  and  a  group  of  later  development,  after 
the  twentieth  day;  the  interval  in  this  case  was  of  in- 
termediate duration).  According  to  Courtois-Sufiit  and 
Giroux,  the  differential  diagnosis  is  not  easy,  since,  besides 


THE  DIAGNOSIS   OF   SHELL-SHOCK  547 

tetanus,  must  be  considered  tetany,  spastic  monoplegia  of 
cerebral  or  spinal  origin,  partial  hemiplegia,  peripheral  neu- 
ritis, contractures  due  to  bone,  joint,  muscle  or  tendon 
lesions,  strychnine  intoxication  and  hysterical  contractures. 
Three  cases  out  of  six  described  by  Routier  were  fatal. 

Re  differential  diagnosis  of  tetanic  conditions,  see  Cour- 
tois-Suffit  and  Giroux  in  the  Collection  Horizon.  The  cases 
as  a  rule  appear  in  subjects  that  have  had  serum  treatment, 
and  may  occur  in  subjects  in  whom  no  trismus  ever  de- 
velops (the  above  case  showed  slight  trismus). 

The  recognition  of  localized  tetanic  contracture  is  based 
upon  {a)  the  intensity  of  the  contracture,  which  causes  the 
limb  to  feel  wooden  (in  one  case  the  foot,  leg,  and  thigh 
were  welded  to  the  pelvis  like  an  iron  bar) ;  (&)  paroxysmal 
contractions  resembling  those  of  tetanus,  confined  to  one 
limb,  and  started  by  a  variety  of  external  causes,  forming 
the  principal  symptom  in  the  disease;  (c)  contracture  of 
comparatively  brief  duration  (hardly  ever  over  two  or  three 
weeks).    A  slight  fever  may  help  in  the  differential  diagnosis. 


548  THE  DIAGNOSIS  OF   SHELL-SHOCK 


Wound  of  left  leg :  Local  spasms,  later  contracture, 
and  painful  crises  (these  associated  with  suppura- 
tion), the  whole  treated  as  tetanic. 


Case  392.     (IVIeriel,  1916.) 

An  infantryman  was  wounded  by  shell  fragments  Septem- 
ber 28,  191 5,  at  \'irginy  and  was  given  a  first  dressing  an 
hour  later  and  a  second  at  the  ambulance,  where  antitetanic 
injection  w^as  also  made.  October  3,  the  patient  arrived  at 
Folk,  showing  a  superficial  wound  of  the  left  frontal  region, 
a  penetrating  wound  of  the  upper  third  of  the  left  thigh,  and 
another  in  the  lower  third  of  the  left  lower  leg. 

The  evening  of  October  8,  the  man  began  to  feel  pain  in 
the  left  leg,  though  the  wounds  looked  well  and  there  was 
no  fever.  October  9,  sudden  involuntary  contractions  of  the 
left  leg  developed,  and  these  increased  in  amplitude  if  the 
limb  was  touched.  The  other  extremities  were  normal. 
Temperature  38.2;   pulse  102.     Restlessness  at  night. 

Next  day  10  c.c.  of  antitetanic  serum  was  administered  and 
more  on  the  nth,  with  chloral  and  isolation;  but  on  the 
evening  of  the  nth,  with  the  contractions  still  completely 
localized  to  the  left  lower  extremity,  came  an  extremely 
painful  crisis  interfering  with  sleep  and  at  last  requiring 
morphine.  Up  to  the  15th  the  antitetanic  injections,  chloral 
and  morphine  were  continued,  but  on  the  15th  the  contrac- 
tions were  replaced  in  part  by  a  contracture  affecting  the 
muscles  of  the  posterior  aspect  of  the  thigh.  In  the  mean- 
time, the  patient  howled  with  pain,  especially  in  the  night. 
Chloral  and  morphine  were  given. 

During  the  next  five  days  the  contractures  and  pains  be- 
came still  more  violent,  and  on  the  21st  the  antitetanic  in- 
jections were  begun  once  more  and  kept  up  through  th^  26th 
in  5  c.c.  doses. 

The  patient  began  to  urinate  in  bed  and  to  be  delirious. 
The  contractions  now  disappeared,  but  the  contracture  per- 
sisted. Antitetanic  serum  was  given  every  other  day  from 
October  28  to  November  2 ;   ever^^  third  day  from  Novem- 


THE  DIAGNOSIS  OF  SHELL-SHOCK  549 

ber  4  to  November  19;  every  fourth  day  from  November  22 
to  December  3;  and  every  fifth  day  from  December  3  to 
December  17.  The  chloral  was  diminished  from  15  to  5 
grams  per  diem  and  by  the  20th  of  December  all  adminis- 
tration of  chloral  had  ceased.  The  morphine  was  given  up 
December  25. 

The  tetanic  symptoms  of  the  left  leg  now  gradually  dimin- 
ished. The  leg,  which  had  been  flexed  at  a  right  angle, 
began  to  extend  little  by  little,  and  the  toes,  which  had  been 
strongly  flexed,  reassumed  their  normal  position.  The 
wounds  suppurated  freely  during  the  tetanic  crises,  but  then 
healed.  In  January  the  man  could  get  up  and  walk,  drag- 
ging his  leg  somewhat,  and  January  20  a  complete  recovery 
had  been  obtained.  There  was  no  hysteria  in  the  history  of 
this  patient,  although  the  man  was  subject  to  "professional  " 
alcoholism,  being  carter  for  a  wholesale  wine  dealer,  drinking 
5  liters  of  wine  a  day 


550  THE  DIAGNOSIS  OF   SHELL-SHOCK 


Shell-shock  by  windage:  Hysterical  paraplegia, 
flaccid  type,  develops  lo  days  later,  after  strain, 
capture,  privation,  recapture.  Paraplegia  at  first 
complete.     Recovery  by  suggestion  (one   stance). 


Case  393-     (Leri,  February,  1915-) 

A  corporal,  21,  told  how  at  Goselmind,  during  the  Sarre- 
bourg  retreat,  August  20,  1914,  a  shell  burst  a  meter  behind 
him,  flattening  his  knapsack,  throwing  him  to  the  ground, 
blowing  him  forward  (as  he  said,  by  the  pressure  of  the 
air)  seven  or  eight  meters,  leaving  him  stunned  though  con- 
scious for  about  twenty  minutes.  Uhlans  fell  upon  him  but 
did  not  trouble  themselves  further  with  him  as  he  could 
not  walk.  He  crawled  along  on  elbows  and  knees  about  a 
kilometer  and  a  half  to  some  Frenchmen  in  a  wood.  He  now 
found  himself  able  to  walk  a  whole  day  supported  by  two 
comrades,  making  about  12  kilometers.  He  got  by  carriage 
to  Gerb^viller,  but  here  fell  again  into  the  hands  of  Germans, 
who  left  him  nine  days  in  the  corner  of  a  barn  without  care. 
Gerbeviller  was  retaken,  and  he  was  evacuated  to  Bayon. 

He  had  now  had  for  some  time  pains  in  the  kidney  region 
below  the  point  struck,  some  difficulty  in  turning  his  head, 
and  some  numbness  and  jerkings  in  the  legs;  and  the  legs 
that  had  carried  him  14  kilometers  were  unable  to  move  at 
all,  even  in  bed.  It  was  only  8  days  later  that  he  could  per- 
form the  slightest  movement,  and  two  months  followed  be- 
fore he  could  go  a  few  steps  on  crutches.  December  14, 
three  months  and  a  half  after  his  accident,  —  he  was  demon- 
strated as  "spinal  contusion."  Upon  examination,  however, 
there  were  no  reflex  disorders,  no  sensory  disorders,  and  the 
muscular  weakness  was  equal  in  all  parts  of  the  lower  ex- 
tremities and  trunk.  On  crutches,  he  lunged  the  trunk  for- 
ward, painfully  dragging  his  legs  one  after  the  other,  the 
right  foot  in  external  rotation,  never  passing  the  left  foot, 
toes  scraping  ground,  —  a  functional  flaccid  paraplegia,  com- 
pletely dissolved  by  suggestion  at  a  single  sitting. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  55I 


Scalp  wound;  probably  no  loss  of  consciousness: 
Quadriparesis,  later  paraplegia;  tremors;  pro- 
found sensory  disorders,  some  apparently  hysteri- 
cal; cataleptic  rigidity  of  (anesthetic)  legs  on 
passive  movement.     Diagnosis? 


Case  394.     (Clarke,  July,  1916.) 

A  soldier,  40,  got  a  scalp  wound  but  probably  did  not  lose 
consciousness.  However,  when  observed  three  months  after 
the  injury,  though  fat  and  well-looking,  the  patient  could  not 
stand  or  walk,  and  his  hands  and  ^arms  were  feeble.  He 
complained  of  headache,  insomnia  and  anorexia,  and  re- 
mained in  a  state  of  mental  inertia.  All  efforts  to  read  and 
write  produced  fatigue.  Memory  was  bad  both  for  remote 
and  for  recent  events.  He  was  able  to  feed  himself  slowly, 
execute  a  few  movements  of  arms  and  hands,  and  raise  his 
feet  from  the  bed.  Upon  passive  movement,  there  was  a 
sort  of  spastic  state,  which  did  not  amount  to  a  true  rigidity. 
Now  and  then  a  clonic  spasm  was  induced  by  such  passive 
movements.  After  the  repetition  of  those  few  voluntary 
movements  which  were  possible,  the  muscles  passed  into  a 
flaccid  condition.  There  was  a  tremor  of  a  type  called 
swooping;  the  tremor  resembled  that  of  Friedreich's  dis- 
ease, such  as  is  thought  to  occur  in  cases  of  marked  loss  of 
muscular  sense.  The  deep  reflexes  were  exaggerated.  Con- 
centric narrowing  of  the  visual  fields  was  easily  induced  by 
testing  them.  There  was  a  general  slight  dulness  of  percep- 
tion on  sensory  tests.  There  was  astereognosis,  and  appar- 
ently an  absolute  loss  of  position  sense.  Movements  of  the 
large  joints  through  an  angle  of  90  degrees  were,  however, 
vaguely  recognized.  Although  the  patient  could  not  touch,, 
for  example,  his  left  forefinger  with  his  right,  yet,  if  he  had 
once  seen  the  position  of  a  limb  and  it  was  not  moved,  he 
could  remember  its  position  and  touch  it  after  some  time. 
His  localizing  sense  was  from  two  to  four  inches  out  in  the 
hands,  the  localization  being  generally  of  points  proximal  to 
the  point  tested. 


552  THE   DIAGNOSIS   OF   SHELL-SHOCK 

Two  months  later  the  patient  was  somewhat  less  dull  and 
apathetic.  His  memory  had  improved.  He  was  able  to 
read,  and  he  was  successfully  making  a  rug;  but  the  legs 
were  worse,  having  become  anesthetic  to  touch  and  pain. 
When  the  legs  were  placed  in  any  position,  they  would  as- 
sume a  cataleptic  rigidity,  and  remain  rigidly  fixed  in  any 
position  for  some  time.  The  patient  could  sit  up  in  bed. 
The  muscles  were  well  nourished  and  the  electric  reactions 
were  normal. 

Re  catatonic  rigidity,  see  Case  389  (Sollier). 


THE  DIAGNOSIS  OF  SHELL-SHOCK  553 


Shell  explosion;  pitched  in  air:    Spasmodic  con- 
tractions of  sartorii,  persistent  in  sleep. 


Case  395.     (Myers,  January,  1916.) 

A  private,  23,  was  admitted  to  a  casualty  clearing  station 
and  the  next  day  told  the  examiner.  Major  Myers,  that  the 
Germans  had  been  sending  whizz-bangs  and  coal-boxes  over, 
and  the  last  he  remembered  was  being  on  guard  and  then 
digging  himself  out  of  fallen  sandbags.  His  comrades  told 
him  that  he  had  been  pitched  in  the  air,  but  this  he  did  not 
remember.  He  remembered  running  to  the  shell  trench, 
but  finding  this  *'  too  hot,"  he  returned  to  the  firing  trench, 
noticing  on  the  way  that  he  could  not  see  well.  He  lay  in 
the  dug-out,  flinching  at  each  shell,  and  "  trying  to  get  into 
the  smallest  possible  corner."  He  tried  to  do  guard  duty  that 
night,  but,  when  some  one  noticed  involuntary  spasmodic 
movements,  he  was  ordered  to  go  back  to  the  dug-out,  was 
helped  to  the  regimental  aid  post  by  two  men,  and  was  sent 
to  hospital.  He  had  been  in  France  eight  months  and  had 
been  shaken  up  somewhat  four  months  before,  when  bombs 
threw  dirt  in  his  face.  At  that  time,  his  hands  and  hand- 
writing had  become  tremulous,  but  he  had  not  reported  sick. 
He  was  depressed  and  wanted  Major  Myers  to  make  him  well. 
It  seems  that  he  had  shrugged  his  shoulders  and  made  leg 
movements,  diving  beneath  the  bedclothes,  and  bringing  his 
knees  to  his  chin.  When  Major  Myers  examined  him,  the 
leg  movements  were  due  solely  "  to  strong  periodic  simul- 
taneous contractions  of  the  two  sartorius  muscles,  the  rate 
of  contraction  of  which  varied  from  60  to  70  per  minute, 
increasing  to  90  during  the  excitement  of  examination." 
There  were  special  changes  of  sensibility  in  the  right  leg  and 
arm  and  right  side  of  the  face  and  chest,  not  involving  the 
abdomen.  The  patellar  reflex  was  exaggerated;  plantar  re- 
flexes could  not  be  obtained.  The  legs  were  tremulous, 
especially  when  the  patient  lifted  them,  whereas  the  hands  and 
tongue  were  only  faintly  tremulous. 


554  THE  DIAGNOSIS   OF  SHELL-SHOCK 

Under  light  hypnosis,  events  in  the  amnestic  period  were 
recalled,  and  details  as  to  the  shell's  direction,  process  of 
lifting  up,  and  fall.  Under  deeper  hypnosis,  the  sartorius 
contractions  diminished  but  did  not  disappear.  Appro- 
priate suggestion  was  made,  and  upon  arousal  from  hypnosis, 
the  movements  ceased,  the  headache  disappeared,  memory 
was  recovered,  and  the  unilateral  disturbances  of  sensibility 
had  vanished. 

As  to  the  possibility  of  malingering  in  this  case.  Major 
Myers  calls  attention  to  the  disorders  of  sensibility  which  he 
believes  could  hardly  have  been  simulated,  to  the  persistence 
of  spasmodic  movements  during  sleep,  to  their  confinement  to 
the  sartorii,  and  to  the  spastic  condition  of  legs,  such  that 
when  the  thighs  were  passively  raised  the  knees  remained 
extended. 

Re  persistence  of  hysterical  phenomena  in  sleep.  Ballet 
felt  that  he  could  prove  that  some  hysterical  contractures 
persisted  during  sleep,  and  Sollier  has  written  a  special 
article  to  the  same  effect.  Ballet's  case  had  a  contracture 
developing  after  an  operation  on  the  first  metacarpal  bone. 
The  contracture  which  followed  would  be  then  probably, 
upon  Babinski's  analysis,  a  reflex  contracture  and  not  a 
hysterical  one.  Duvernay,  Sicard,  and  Babinski  himself 
have  noted  the  persistence  of  reflex  contractures  during 
sleep,  to  say  nothing  of  their  persistence  under  an  advanced 
stage  of  chloroform  narcosis.  In  fact,  these  reflex  contrac- 
tures are  exactly  as  fixed  and  persistent  as  contractures  of 
clearly  organic  origin.  It  is  probable  that  Babinski  would 
define  Myers'  case  (395)  as  a  physiopathic  one;  yet  against 
this  diagnosis  would  be  the  disappearance  of  the  movements 
after  hypnosis.  As  against  hysteria,  it  will  be  noted  that 
the  patellar  reflex  was  exaggerated,  and  that  the  plantar 
reflexes  could  not  be  obtained. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  555 


Shell-shock:    Brown-S^quard   syndrome,  hemato- 
myelic  ? 


Case  396.     (Ballet,  August,  191 5.) 

A  soldier,  24,  went  to  the  front  November  12,  1914,  and 
June  I,  19 1 5,  had  a  shell  burst  near  him  In  the  trench,  on  the 
occasion  of  which  he  felt  a  violent  shock,  as  If  a  blow  In  the 
kidneys.  He  felt  suddenly  paralyzed  In  both  legs.  He  was 
crouching  at  the  time  of  the  shell  burst.  His  legs  felt  dead, 
and  he  had  such  violent  pain  in  the  thorax  as  to  make 
breathing  difficult.  He  was  carried  to  a  shelter.  After  a 
few  hours,  the  left  leg  began  to  move  again. 

He  was  carried  to  the  ambulance,  remaining  there  five  days, 
unable  to  walk,  though  able  to  move  and  turn  In  bed, 
slightly  constipated,  with  persistent  pains  in  back.  He  was 
then  carried  to  Auxiliary  Hospital  231,  at  Paris,  and  a 
bullet  ( ! )  was  found  superficially  lodged  In  the  region  of  the 
left  scapula.  Neither  patient  nor  physicians  had  hitherto 
observed  the  bullet,  which  could  have  had  nothing  to  do  with 
any  spinal  lesion. 

The  pains,  in  the  course  of  a  month,  grew  less,  and  at  the 
end  of  two  or  three  weeks  he  began  to  walk  and  was  sent  to 
the  psychoneurosis  service  at  Ville-Evrard,  July  10.  He 
then  complained  of  pain  in  the  right  thorax,  especially  on 
movement  or  after  sitting  up  some  time.  He  could  hardly 
bring  himself  to  the  sitting  posture  from  the  bed,  and  found 
difficulty  in  raising  the  right  leg  therefrom.  In  walking,  the 
right  leg  was  dragged  behind.  The  reflexes  were  Increased  on 
the  right  side.  There  was  ankle  clonus  without  Babinski 
sign.  Anesthesia  to  touch  over  the  whole  of  the  left  leg. 
Anesthesia  to  pin  prick  and  temperature  as  far  as  the  um- 
bilicus.    Cold  was  not  felt  on  the  left  side. 

The  water  of  a  bath  seemed  lukewarm  on  the  left  side  and 
warm  on  the  right.  The  left  side  of  the  scrotum  and  the  left 
half  of  the  penis  showed  the  same  disorder  of  sensibility. 
There  was  a  zone  of  hypesthesia  on  the  right  side  of  the  thorax 
in  the  region  of  the  lower  ribs.     The  patient  compared  his 


556  THE  DIAGNOSIS   OF  SHELL-SHOCK 

sensations  while  at  rest  and  without  contact  to  a  sensation  of 
painful  pressure  occurring  intermittently,  or  rather  in  par- 
oxysms, not  advancing  beyond  the  median  line  of  the  back. 
Here  was  a  question  of  Brown-Sequard  syndrome,  probably 
due  to  a  slight  hematomyelia,  but  associated  with  no  ex- 
ternal lesion  or  any  injury  to  the  vertebral  column. 

Re  Brown-Sequard 's  syndrome,  see  Athanassio-Benisty 
with  respect  to  spinal  cord  symptoms  associated  with  lesions 
of  the  brachial  plexus.  It  appears  that  the  combination  of 
spinal  cord  and  brachial  plexus  injury  is  not  uncommon. 
Note  in  this  case  that  a  bullet  was  found  in  the  left  scapula 
region.  According  to  Ballet,  this  bullet  could  have  had 
nothing  to  do  with  a  spinal  lesion. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  557 


Violence  to  back ;  Dysbasia.     Antebellum  injury. 


Case  397.     (Smyly,  April,  191 7.) 

A  man  (also  injured  in  1906  by  the  fall  of  a  heavy  weight 
on  his  back)  went  to  France  in  19 14  as  a  soldier,  and  eight 
months  later  was  hurled  into  a  shell  hole  so  that  his  back 
struck  the  edge.  He  was  rendered  unconscious.  Upon  re- 
covery of  consciousness,  the  right  leg  was  found  to  be  swollen, 
and  there  were  severe  pains  In  the  legs  and  back. 

Upon  return  home  the  patient  went  from  one  hospital  to 
another,  for  the  most  part  unable  to  walk,  suffering  from 
agonizing  pain  in  head  and  eyes.  Insomnia  and  waking 
dreams. 

He  was  able  to  bring  himself  to  an  upright  position  and  to 
rush  a  few  steps.  He  has  now  acquired  considerable  control 
of  the  feet  by  the  aid  of  crutches.     Insomnia  persisted. 


Dysbasia:  Psychogenic  (cerebellar  nucleus  (?)) 


Case  398.     (Cassirer,  February,  191 6.) 

On  March  9,  191 5,  a  shell  wounded  a  man  slightly,  and 
burned  off  some  of  the  hair  of  his  head.  He  was  uncon- 
scious two  days,  and  on  waking  vomited  for  a  time.  Shortly 
after  the  Injury  difficulties  in  standing  and  walking  set  in, 
with  headache,  noises  in  the  left  ear,  difficulty  in  the  Intake  of 
Ideas,  excitability,  and  poor  memory.  Then,  slight  improve- 
ment. About  the  middle  of  June  he  was  no  longer  closely 
confined  to  bed  and  could  take  a  few  steps  with  tw^o  canes; 
but  the  gait  was  still  unsteady  and  the  left  leg  tended  to  make 
abnormal-looking  movements.  There  was  nystagmus,  rapid, 
though  constant,  on  looking  to  the  left,  —  more  In  the  left 
eye;  and  nystagmus  on  looking  to  the  right,  —  more  In  the 
right  eye.  Adiadochoklnesis  absent.  Vestibular  nerve  some- 
what excitable.     Deviation  outward  in  finger-pointing  test. 

According  to  Cassirer,  this  case  is  one  largely  of  psychogenic 
origin,  with  possibly  an  organic  cerebellar  nucleus.  The  knee- 
jerks  absent  (even  up  to  March  31).     W.  R.  negative. 


558  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Shell-shock ;    unconsciousness :    Dysbasia,  in  part 
hysterical,  in  part  organic  (?). 


Case  399.     (Hurst,  May,  1915.) 

A  private,  29,  was  knocked  over  by  a  shell  explosion 
December,  19 14.  He  was  unconscious  two  days,  found  that 
he  could  not  move  either  right  arm  or  left  leg,  got  some 
power  back  shortly,  but,  if  he  tried  to  stand,  experienced  in- 
voluntary violent  movements  in  the  left  leg. 

April  I,  191 5,  response  to  questions  was  slow  and  speech 
slow.  The  right  arm  and  grip  were  weak.  If  the  left  hand 
was  clenched,  there  was  an  associated  movement  of  the  right 
hand;  but  on  clenching  the  right  hand,  no  associated  move- 
ment was  produced  in  the  left.  The  musculature  was  equal 
on  the  two  sides,  and  the  tendon  reflexes  of  the  arms  were 
brisk  and  equal.  Light  tactile  stimuli  were  hard  to  localize. 
Movements  of  the  left  leg  were  somewhat  weak,  though  the 
musculature  was  equal  on  the  two  sides.  The  knee-jerks 
were  brisk,  the  left  slightly  brisker.  Sometimes  a  well- 
marked  ankle  clonus  could  be  obtained  on  the  left  side,  but 
sometimes  not.  The  plantar  reflex  was  constantly  flexor. 
Babinski's  second  sign  (combined  flexion  of  thigh  and  pelvis) 
was  well  marked  on  the  left  side. 

On  attempts  to  walk,  the  left  leg  would  move  rapidly  from 
side  to  side,  round  the  point  of  contact  of  toes  with  ground. 
When  a  step  forward  was  taken  with  the  right  leg,  the  left 
one  dragged,  and  made  irregular  movements. 

This  gait  seemed  obviously  hysterical.  The  patient  was 
kept  in  hospital  for  a  month.  He  was  very  easily  hypno- 
tizable,  but  even  in  deep  hypnosis  leg  movements  could  not 
be  controlled  when  he  was  told  to  walk.  The  first  whiff  of 
ether  hypnotized  but  did  not  cure  him. 

On  the  whole,  upon  review.  Hurst  believes  that  there  may 
have  been  organic  brain  changes,  which  (a)  the  associated 
movement  of  the  paralyzed  hand  when  the  normal  hand  was 
contracting,  {b)  the  slightly  increased  left  knee-jerk,  (c)  tend- 
ency to  ankle-clonus,  and  {d)  Babinski's  second  sign,  may 
show. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  559 


Peculiar  walking  tic. 


Case  400.     (Chavigny,  April,  1917.) 

A  soldier  was  found  with  a  peculiar  walking  tic.  He  would 
rest  a  good  deal  longer  on  the  left  leg  than  on  the  right.  He 
would  make  a  sudden  movement  of  the  right  leg  forward,  as 
if  on  a  spring.  At  the  same  time,  the  man's  head  would  give 
a  violent  movement  to  the  right  just  as  the  right  leg  was 
receiving  the  weight  of  the  body.  The  idea  of  this  move- 
ment seemed  to  be  that  the  center  of  gravity  would  be  shifted 
and  the  work  of  the  right  leg  would  be  relieved.  This  peculiar 
walk  was  naturally  very  slow.  If  the  walk  was  slowed  down, 
it  became  quite  normal.  There  was  no  pain  at  the  basis  of 
this  walk.  If  the  man  hopped,  he  hopped  no  more  painfully 
on  the  right  leg,  nor  with  greater  difficulty,  than  upon  the 
left. 

This  man  was  guilty  of  desertion  In  the  face  of  the  enemy, 
and  of  desertion  in  the  interior  in  time  of  war.  He  said  he 
could  not  walk  well  and  that  he  needed  to  take  care  of  himself 
at  his  mother's  house,  as  he  was  not  considered  sick  in  his 
regiment.  He  had  been  wounded  with  two  bullets,  September 
28,  1914,  which  struck  him  on  the  internal  aspects  of  the 
knees.  He  was  treated  in  hospital  from  October  to  the  end 
of  November,  19 14;  was  held  at  the  depot  of  his  regiment 
from  December  to  August,  1915.  He  was  then  put  in  hospital 
a  month,  and  returned  to  his  depot  for  three  more  months. 
He  was  examined  by  three  physicians  in  August,  191 5,  and  the 
commission  decided  that  he  was  fit  for  service,  and  a  simu- 
lator. 

Thorough  examination,  Including  electrical  and  X-ray 
examinations,  showed  no  lesion.  Chavigny  observed  the 
patient  for  a  long  time,  from  the  21st  of  November,  1916,  to 
January  5,  191 7.  Shells  dropped  near  the  hospital,  Decem- 
ber 2,  and,  following  orders,  the  patients  were  taken  into  a 
vaulted  cellar,  and  they  ran  thither  very  rapidly;  but  this 
patient  could  not  hurry.  He  walked  slowly,  with  the  same 
tic.     Surely  the  tic  would  be  rather  a  difficult  one  to  imagine, 


560  THE   DIAGNOSIS   OF   SHELL-SHOCK 

and  a  somewhat  more  probable  set  of  symptoms  would 
ordinarily  be  chosen.  The  man  has  not  the  unstable  nature 
of  the  ordinary  victim  of  tic.  On  the  contrary,  he  has  rather 
the  invincible  obstinacy  of  a  hysterotraumatic.  On  being 
shown  that  he  could  walk  properly  without  these  "para" 
movements,  he  would  reply,  "  I  can't  do  anything  else,"  and 
he  shook  his  head  upon  being  told  that  he  could  be  cured. 

Reeducation  of  his  anesthetic  areas  (there  was  a  zone  of 
diminution  in  sensibility  to  pin-prick  in  the  knee  region,  and 
a  complete  anesthesia  of  the  sole  of  the  foot,  with  abolition  of 
the  plantar  reflex),  reeducation  by  appropriate  gymnastics, 
and  mental  reeducation,  might  be  attempted  in  a  special  neu- 
rological hospital. 

Re  disorders  of  gait,  Laignel-Lavastine  and  Courbon  divide 
functional  gait  disorders  into  three  groups:  (a)  A  group 
called  dynamogenic;  (6)  an  inhibitory  group;  and  (c)  a 
group  showing  both  forms  of  disorder. 

Roussy  and  Lhermitte  have  attempted  to  divide  the  gait 
disorders  into  two  groups:  (a)  A  group  termed  by  them 
basophobic,  in  which  there  is  a  marked  psychogenic  and 
emotional  basis;  and  {h)  a  dysbasic  group,  the  basis  of 
which  is  suggestion  rather  than  emotion.  Following  is  a 
skeleton  of  their  classification: 

1.  Astasia-abasia  and  dysbasia  group. 
Astasia-abasia  Choreiform  dysbasia. 
Pseudo  tabetic  dysbasia.  Knock-kneed  gait. 
Pseudo  polyneuritic  dysbasia.      Walking  as  if  on  sticky 
Tight-rope  walker's  gait.  surface. 
Scrubber's  gait.                               Bather's  gait. 

2.  Stasobasophobia  group. 

3.  Habit  limping. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  56I 


Mine  explosion ;  unconsciousness :  Camptocormia. 
Hospital  rounder  twenty  months  (bedfast  five 
months)  without  complete  neurological  examination. 
Cure  by  persuasive  electrotherapy  in  one  hour. 


Case  401.  (]\Iarie,  ^vIeige,  Behagxe,  February,  1917; 
SouQUES  and  ]\Iegevand,   February,   1917.) 

A  man  became  a  hospital  rounder  to  all  points  of  the  com- 
pass in  France  during  a  period  of  twenty  months,  with  such 
diagnoses  as  myelopathic  disorder,  complex  spinal  trouble, 
ataxic  phenomena. 

As  a  matter  of  fact  he  was  a  camptocormic:  trimk  bent, 
knees  semi-flexed,  legs  in  external  rotation.  He  used  two 
canes  in  locomotion,  made  a  bo\\-ing  movement  with  each 
20  cm.  step,  then  another  bowing  movement,  and  another 
little  step  with  the  other  foot.  ]\Iade  to  lie  dovv-n,  his  legs 
would  elongate,  the  right  completely  but  the  left  with  some 
difficulty,  the  feet  going  into  hyperextension,  with  the  big 
toe  raised,  others  flexed;  the  feet  externally  rotating,  plantae 
turned  in.  In  horizontal  decubitus,  there  was  only  slight 
lumbar  discomfort,  but  the  legs  stiffened  and  gave  quick 
convulsive  jerks.  Taking  the  posture  several  times  in  suc- 
cession would  diminish  these  phenomena.  Kneeling,  he 
could  bring  his  heels  within  10  cm.  of  the  buttock,  whereas 
in  spontaneous  flexion  of  the  leg  on  the  thigh,  the  knee  re- 
mained a  distance  of  40  cm.  from  the  buttock. 

A  complete  examination  shovv^ed  no  joint  disorder  or  any 
diminution  in  muscular  strength,  or  any  reflex  disorder  ex- 
cept that  all  the  tendon  reflexes  were  rather  powerful.  There 
was  a  question  of  possible  X-ray  demonstration  of  lesions  and 
ankylosis  of  the  fourth  and  fifth  lumbar  vertebrae,  and  there 
was  a  question  of  some  incontinence  of  urine.  On  the  basis 
of  these  phenomena  apparently,  this  camptocormic  patient 
had  been  saddled  with  the  diagnosis  of  myelopathic  and 
ataxic  disorder  for  a  period  of  16  months.  A  neurologist  was 
at  last  consulted;  and  on  his  advice,  it  proved  possible  to  get 
the  patient  evacuated  to  a  neurological  center  in  a  period  of 


562  THE  DIAGNOSIS   OF   SHELL-SHOCK 

four  months.  Facts  of  this  species  are  unfortunately  still  too 
common,  state  Marie,  Meige  and  B6hagne,  February  i,  1917, 
despite  the  remarkable  and  rapid  cures  obtained  in  campto- 
cormia  by  Souques.  In  point  of  fact,  no  complete  neuro- 
logical examination  had  been  performed  upon  this  man 
during  a  period  of  20  months. 

This  particular  patient  was  given  to  Souques  for  treatment 
(Souques  and  Megevand).  His  cure  was  completed  by  per- 
suasive electrotherapy,  in  an  hour. 

It  appears  that  the  man  was  buried  in  a  mine  explosion, 
June  5,  1 91 5,  lost  consciousness  and  came  to  twenty  hours 
later,  able  to  rise  and  take  a  few  steps,  but  bent  in  two 
with  a  sharp  dorsolumbar  pain.  The  pain  grew  more  violent 
and  generalized  during  the  next  few  days,  and  he  began  to 
lose  all  power  in  his  legs,  so  that  he  could  walk  with  the 
greatest  difficulty.  He  was  practically  bedfast  for  five 
months.  He  then  tried  to  rise  and  walk,  but  suffered  so 
much  that  he  could  not  get  up  except  in  a  camptocormic 
position.  It  was  in  fact  only  January  23,  191 7,  at  the 
Salpetriere,  that  the  diagnosis  of  camptocormla  was  made. 
The  man  complained  of  pains  at  the  lower  dorsal  and  lumbar 
regions  of  the  spinal  column  with  slight  irradiation  sidewise. 
The  following  diagnoses  had  been  made: 

June  8,  191 5.     Severe  contusion  of  chest  and  back. 

July  9,  1915.  ^Multiple  contusions,  commotio  spinalis; 
lesions  and  ankylosis  of  the  4th  and  5th  lumbar  vertebrae 
(X-ray  examination). 

Sept.  3,  1916.  Lumbar  intervertebral  arthritis  with  com- 
pression of  roots. 

Nov.  4,  191 6.     Myelopathic  disorder. 

Dec.  5,  1 91 6.     Old  complex  spinal  disorder. 

Souques  remarks  that  these  diagnoses  show  that  knowledge 
about  camptocormia  has  not  penetrated  into  most  of  the 
sanitary  formations  (19 17). 


THE   DIAGNOSIS   OF   SHELL-SHOCK  563 


Astasia-Abasia. 


Case  402.     (GuiLLAiN  and  Barre,  January,  1916.) 

A  soldier  was  evacuated  to  the  6th  Army  neurological 
center  for  paraplegia  with  tremor.  He  had  been  in  various 
hospitals  for  a  period  of  a  year.  The  tendon  reflexes  of  the 
arms  appeared  increased;  there  was  a  suspicion  of  patellar 
clonus  and  of  foot  clonus,  and  it  had  been  proposed  to  invalid 
the  man  for  spastic  paralysis.  In  point  of  fact,  the  man  was 
suffering  from  an  epileptoid  trepidation  of  the  foot  and  of  the 
patella.  When  he  was  lying  down,  his  motor  disorders  prac- 
tically passed  away,  though  they  had  been  very  marked  when 
he  tried  to  stand  upright  or  to  walk.  He  had  much  trouble 
in  walking,  but  could  readily  stand  for  some  time  on  one  leg. 

The  man  was  forthwith  treated  by  persuasive  methods. 
It  is  important  to  find  out  the  organic  lesion  which  in  all 
probability  served  as  a  starting  point  for  the  functional 
disease,  and  important  to  remove  or  abolish  this  lesion  how- 
ever minute  if  a  complete  and  lasting  cure  is  to  be  obtained. 

Re  astasia-abasia,  writers  have  remarked  that  it  is  one  of 
the  commonest  hysterical  syndromes  in  the  war,  though 
somewhat  rare  in  its  complete  form.  Roussy  and  Lher- 
mitte  state  that  it  usually  follows  the  explosion  of  a  large 
calibre  projectile  and  has  a  rapid  onset.  It  is  often  an  iso- 
lated phenomenon,  without  emotional  or  other  Shell-shock 
complications.  The  victim  has  been  thrown  to  the  ground 
and  rolled  into  a  trench  or  hollow.  Sometimes  the  victim 
gets  back  to  the  first-aid  post,  only  to  find  himself  on  arrival 
at  the  ambulance  wholly  unable  to  walk.  The  legs,  however, 
are  drawn  along  inertly,  as  in  paraplegia,  or  a  pronounced 
contracture  interferes  with  walking. 

Astasia-abasia  is  classified  with  hysteria  major,  hysterical 
hemiplegia,  hysterotraumatic  brachial  monoplegia,  glosso- 
labial  hemispasm,  hysterical  mutism,  and  rhythmic  chorea, 
as  so  characteristic  that  differential  diagnosis  is  superfluous. 
According  to  Babinski,  no  functional  spasm  and  no  organic 
disease  can  reproduce  hysterical  astasia-abasia. 


564  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Multiple  shell  wounds,  with  persistent  slight  sup- 
puration of  thigh:  Abdominothoracic  contracture, 
tetanic,  four  months  after  original  injury. 


Case  403.     (Marie,  1 916.) 

A  soldier,  31,  was  wounded  in  the  left  arm  January,  1915, 
and  received  10  c.c.  antitetanic  serum;  was  wounded  again 
July  10  in  the  face,  scalp,  upper  part  of  the  thorax,  left  arm 
and  left  leg  by  shell  fragments,  and  again  received,  two  days 
later,  10  c.c.  antitetanic  serum.  July  13,  at  the  ophthal- 
mological  center  at  Rouen  the  left  eye  was  enucleated  on 
account  of  a  shell  wound,  and  four  days  later  a  fragment  was 
removed  from  a  phlegmon  of  the  forearm.  Later  a  number 
of  operations  were  made  for  blepharoplasty.  The  wounds 
all  healed  well  except  for  an  apparently  insignificant,  small 
suppuration  of  the  thigh.  November  10,  four  months  after 
the  shell  wounds,  while  apparently  in  perfect  health,  the  man 
began  to  complain  of  lancinating,  intermittent  pains  in  the 
abdomen,  thorax  and  lumbar  region.  With  these  pains  was 
associated  a  persistent  abdomlnolumbar  contracture. 

On  the  suspicion  of  an  abdominal  form  of  local  tetanus, 
chloral  was  given ;  but  the  condition  grew  worse.  The  sudden 
contractions  spread  from  the  waist  to  the  feet,  from  November 
20  onward,  and  were  felt  by  the  patient  as  electric  shocks. 
The  arms  were  not  affected.  Trouble  with  breathing  super- 
vened on  the  night  of  December  3.  Sometimes  there  were 
respiratory  pauses  for  as  long  as  15  seconds,  followed  by  a 
slight  polypnea.  December  6  the  man  presented  an  intense 
contracture  of  the  lower  part  of  the  trunk.  The  slightly 
retracted  abdominal  wall  was  of  marbly  hardness,  but  quite 
painless.  Analgesic  muscular  rigidity  took  the  place  of  the 
former  crises  of  pain.  The  dorsolumbar  contracture  "yv^as  so 
marked  as  to  make  an  appreciable  hollow  In  the  back.  The 
patient  could  pick  up  an  object  from  the  ground  only  by 
flexing  his  knees  to  the  maximum,  as  the  trunk  could  not  be 
flexed.  There  was  a  very  slight  trismus,  but  he  could  open 
his  mouth,  drink,  eat  and  talk  without  difficulty.     There  was 


THE   DIAGNOSIS   OF   SHELL-SHOCK  565 

no  trace  of  neck  stiffness  or  of  Kernig's  sign.  The  tendon 
reflexes,  normal  in  the  arms,  were  exaggerated  in  the  lower 
extremities,  especially  on  the  left  (wounded)  side.  The  skin 
reflexes  were  also  more  marked  on  the  left  side,  especially  the 
reflex  of  the  tensor  of  the  fascia  lata.  There  was  no  longer 
any  e\ddence  of  suppuration  of  the  wound  of  the  left  thigh, 
which  had  been  dried  up  for  a  fortnight.  The  pulse  was 
somewhat  exaggerated  (92)  and  there  was  a  general  hyper- 
idrosis,  especially  of  the  face. 

Forty  c.c.  antitetanic  serum  were  given  without  reaction, 
and  4  grams  of  chloral;  five  days  later,  30  c.c.  more  serum. 
After  ten  days  the  abdomen  remained  hard,  though  there  was 
a  trifling  improvement  of  the  lumbar  contracture.  There 
were  no  longer  any  spasmodic  crises  or  respiratory  disturb- 
ances. There  was  a  slight  serous  exudation  from  the  wound. 
X-ray  showed  a  small  shell  fragment  6  cm.  below  the  orifice 
of  the  wound. 

The  third  injection  was  given  December  27  to  prevent 
mobilization  of  the  bacilli  at  operation,  and  on  the  28th,  the 
projectile  was  removed  under  local  anesthesia  from  a  small, 
walled-ofT,  old  pus  pocket,  from  which  were  cultivated  bacillus 
perfringens  and  other  organisms. 

December  31  a  distinct  improvement  set  in  and  January 
13  there  was  little  or  no  trace  of  previous  disease,  except  that 
testing  the  plantar  cutaneous  reflex  on  the  left  side  produced 
an  exaggerated  contraction  of  the  tensor  of  the  fascia  lata. 
February  15  he  was  reexamined  and  found  quite  normal. 

This  case  of  tetanus  limited  to  the  abdominothoracic 
muscles  (except  for  a  very  mild  contracture  of  the  masti- 
cators) had  as  its  locus  of  origin,  doubtless,  a  wound  of  the 
thigh  from  which  the  toxin  rose  along  branches  of  the  lum- 
bar plexus  to  impregnate  the  corresponding  level  of  the  spinal 
cord.  Although  there  was  no  stiffness  of  the  wounded  leg, 
yet  there  was  an  exaggeration  of  the  tendon  reflexes  thereof. 
The  first  phase  of  painful  contractures  and  spasms  with 
respiratory  disorder  was  succeeded  by  an  analgesic  phase  of 
characteristically  tetanic  rigidity.  The  nonfebrile  nature  of 
the  disease  and  the  preser\^ation  of  good  general  health  are 
worth  noting. 


566  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Shoulder  blade  unslung  in  knock-down  by  shell 
splinter:  Hysterical  (!)  paralysis  of  arm  with 
anesthesia.  Recovery  by  electricity,  massage,  and 
reeducation  (dislocation  remaining). 


Case  404.     (Walther,  December,  1914.) 

A  soldier  was  struck  September  27,  near  Berry  au  Bac,  by 
a  shell  fragment  in  the  right  scapular  region  and  was  thrown, 
according  to  his  story,  15  meters.  Upon  entrance  at  Val-de- 
Grace,  October  13,  the  shoulder-girdle  was  found  intact. 
There  was  a  very  painful  point  in  the  spinous  process  of  the 
scapula,  suggesting  a  fracture;  but  the  bone  was  proved  In- 
tact on  X-ray.  The  scapula  was  very  mobile,  as  if  unslung 
from  the  thorax.  The  arm  was  paralyzed.  On  raising  the 
arm  the  scapula  followed  its  movements  and  detached  itself 
completely  from  the  thorax,  dislocating  upwards  with  lively 
pain.  The  fingers  could  be  pushed  under  the  anterior  surface 
of  the  scapula,  and  Its  Internal  border  proved  to  be  entirely 
free  of  attachment.  Pressure  along  this  Internal  border  was 
very  painful.  It  seems  as  if  there  had  been  a  tearing  of  the 
rhomboid  and  serratus  magnus  muscles  and  probably  a  part 
of  the  latlsslmus  dorsi  under  the  influence  of  the  violent 
shock  conveyed  by  the  shell  fragment,  which  had  pushed  the 
scapula  forward  and  upward  without  Injuring  the  skin. 

There  was  also  a  complete  paralysis  of  sensation.  Paraly- 
sis of  motion  was  complete  except  for  the  extensor  longus  of 
the  thumb.  This  motor  paralysis  had  come  on  progres- 
sively three  days  after  the  accident.  A  radicular  paralysis 
from  an  evulsion  of  the  plexus  was  suspected. 

Bablnski,  however,  made  the  diagnosis  of  psychic  paralysis, 
finding  the  muscles  reacting  perfectly  to  percussion.  After 
a  few  electric  tests  with  the  faradic  current  voluntary  move- 
ments were  obtained  In  all  the  muscles  of  the  arm  and  hand. 

Treatment  was  then  continued  by  electricity,  massage  and 
reeducation,  so  that  all  movements  soon  regained  strength. 
The  patient  can  now  himself,  by  raising  his  arm,  still  produce 
his  dislocation,  which  still  provokes  a  lively  pain. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  567 


Gunshot  wound  of  left  forearm:  PARALYSIS  of 
the  arm  graduaUy  INCREASING  IN  DEGREE  and 
extent  and  associated  with  pains  and  anesthesias. 


Case  405.     (Oppenheim,  July,  191 5.) 

A  reservist  sustained,  October  2,  1914,  a  gunshot  wound 
of  the  left  forearm  from  a  distance  of  about  1400  meters.  He 
fainted,  lost  much  blood,  and  was  treated  surgically,  October 
7,  in  hospital  (at  this  time  no  complete  paralysis  of  the  arm). 

In  November,  however,  an  incomplete  paralysis  at  first 
developed.  November  12,  the  patient  was  able  to  flex  his 
thumb  but  showed  some  anesthesia. 

Transferred  to  nerve  hospital  in  December,  the  patient 
said  that  at  the  first  change  of  dressings,  October  10,  he  had 
not  been  able  to  move  his  arm,  and  said  that  pains  and  pares- 
thesia had  existed  in  the  arm  ever  since  the  injury.  There  was 
still  some  evidence  of  suppuration  at  the  exit  orifice  of  the 
bullet.  The  left  arm  was  now  completely  paralyzed  and 
atonic,  and  hung  down  in  walking,  without  swinging.  The 
supinator  phenomenon,  though  present  on  the  right  side,  was 
absent  on  the  left.  The  triceps  reflex  was  present.  The 
shoulder  acted  like  a  flail  joint.  On  passive  elevation  of  the 
left  arm,  the  deltoid  seemed  to  contract  slightly  at  first ;  later 
it  failed  to  contract.     Fibrillary  tremor  of  the  left  thumb. 

Suggestive  therapy  was  unsuccessful.  There  was  an  an- 
esthesia of  the  left  arm  and  the  left  trunk.  The  disorder 
diminished  proximally,  being  most  severe  in  the  hand  and 
the  arm.  The  legs  were  normal.  The  electrical  irritability 
of  the  left  arm  was  only  slightly  diminished.  There  was  a 
well-marked  hypertrichosis  of  the  left  forearm,  the  skin  of 
which  was  slightly  purple  and  discolored.  The  patient  him- 
self made  an  attempt  to  burn  his  arm  with  a  lighted  cigar,  to 
see  if  he  could  feel  the  pain.  He  showed  the  scar  but  had 
felt  nothing.  The  pectoralis  major  muscle  did  not  contract. 
If  the  left  arm  was  started  actively  swinging,  it  kept  on 
swinging  inertly.  The  left  hand  showed  hyperidrosis.  The 
small  hand  muscles  were  emaciated  but  electrically  normal.] 


568  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Glass  wound  of  wrist:  Differential  glove  anes- 
thesias (cold  to  mid  forearm,  pain  somewhat  higher, 
touch  as  far  as  elbow). 


Case  406.     (RoMNER,  March,  191 5.) 

A  German  soldier,  37,  wounded  his  right  wrist  in  the  glass 
of  a  door.  The  hand  was  put  up  six  weeks  long  with  very- 
few  clianges  of  the  bandage  on  account  of  suppuration,  and 
he  noticed  that  the  arm  was  getting  weaker  and  weaker,  that 
he  was  losing  feehng  in  it,  and  that  it  was  beginning  to  sweat 
a  good  deal,  so  that  now  and  tlien  drops  of  sweat  would 
stream  off.  The  right  hand  was  found  markedly  congested 
and  1.5  cm.  larger  in  circumference.  The  lingers  and  hand 
were  esixx  ially  weak.  There  was  a  marked  tremor  of  the  arm. 
Electric  excitability  normal.  The  sensory  disorder  was  in 
glove  form.  Hypesthesia  to  touch  reached  the  elbow,  anal- 
gesia to  a  point  three  fingers'  breadth  below  the  elbow,  and 
anesthesia  to  cold  to  a  point  two  fingers'  breadth  still  lower, 
a  sort  of  stepwise  dissociation  of  sensibility  resembling  what 
is  found  in  spinal  lesions.  The  case  was  presented  as  one  of 
local  traumatic  hysteria. 

Re  hysterical  anesthesia,  the  rule  is  that  it  obeys  no  definite 
rule;  that  is,  it  may  be  a  hemianesthesia,  a  segmentary,  an 
isolated,  or  even  a  pseudo-peripheral  anesthesia.  It  is  a  ques- 
tion whether  Babinski  would  attempt  to  explain  Romner's 
case  on  the  basis  of  medical  suggestion,  hetero-suggestion, 
or  autosuggestion. 

TNlyers  has  had  a  few  instances  in  which  anesthesia  spread 
gradually,  and  in  which  analgesia  increased  alter  its  onset. 

Re  reeducation  of  cutaneous  sensations,  Chavigny  recom- 
mends the  faradic  current  in  successive  applications,  mark- 
ing the  extent  of  the  zone  of  anesthesia  with  ink  upon  the 
skin.  Each  time  the  current  is  applied,  the  inked  liniits  of 
the  area  are  lessened.  By  this  form  of  suggestion,  not  only 
does  the  anesthesia  disappear,  but  very  often  the  accom- 
panying paralysis  also. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  569 


Hysterical  contracture,  edema  and  vasomotor  disorder. 


Case  407.     (Ballet,  July,  1915.) 

For  some  unknown  reason,  a  soldier  developed  a  contrac- 
ture of  the  right  upper  and  lower  extremities  at  a  time  when 
a  basin  of  water  was  offered  to  him  for  toilet  purposes.  Three 
days  later,  this  contracture  disappeared  in  the  leg  but  per- 
sisted in  the  arm  at  the  radiocarpal  joint  and  in  the  finger 
joints.  There  was  also  an  anesthesia  to  touch  and  pain  and 
temperature  which  ran  up  the  arm  to  the  shoulder.  The  ten- 
don reflexes  were  normal.  On  the  whole,  there  seemed  to  be 
no  doubt  that  the  case  was  one  of  hysterical  arm  contracture. 
Associated  with  this  contracture  was  a  white  edema  of  the 
hand.  On  account  of  the  chances  of  simulation,  the  hand 
was  done  up  and  sealed  in  such  wise  that  the  seals  would  have 
been  broken  if  the  splint  had  been  lifted  down  during  the 
night.  The  bandage  was  in  place  from  June  25  to  June  29. 
Upon  its  removal,  there  was  no  edema,  but  the  contracture 
was  still  there.  The  arm  was  put  up  upon  a  cushion  so  that 
the  hand  would  drain  to  the  forearm.  The  edema  was  found 
capable  of  returning  when  the  hand  was  placed  below  the 
level  of  the  shoulder,  disappearing  when  the  hand  was  raised. 
The  contractured  hand  was  warmer  than  its  fellow.  Accord- 
ing] to  Ballet,  we  here  have  an  anesthetic  instance  |^of  con- 
tracture associated  with  edema  and  vasomotor  disorder. 

Re  edema,  Babinski  states  that  no  case  of  hysterical  edema 
has  stood  the  test  of  scientific  critique.  Sometimes  a  case 
turns  out  one  of  tuberculous  synovitis.  Sometimes  the 
patient  is  shown  artificially  to  have  brought  about  the  edema. 
The  hysterical  "blue  edema"  of  Charcot  has  not  been  proved 
to  exist.  Some  during  the  war  have  been  found  due  to  vol- 
untary constriction.  Some  of  these  constriction  edemas  even 
become  relatively  permanent.  Babinski  regards  the  above 
case  of  Ballet,  as  well  as  cases  of  Lebar  and  of  Raynaud,  as 
not  true  cases.     Raynaud's  case  was  probably  vascular. 

Re  vasomotor  disorders  in  Ballet's  case,  the  Babinski  school, 
of  course,  holds  that  hysteria  cannot  cause  such  disorders. 


570  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Hemiparesis   with   syringomyelic    dissociation    of 
sensations. 


Case  408.     (Ravaut,  August,  191 5.) 

A  road-laborer,  42,  in  the  268th  Infantry,  had  a  bomb 
burst  about  a  meter  away,  March  4,  191 5.  Three  men  near- 
by were  killed,  and  two  wounded.  The  laborer  himself 
was  turned  over,  covered  with  earth,  and  stunned.  He  could 
hardly  get  up.  He  was  carried  to  shelter  and  found  para- 
lyzed on  the  left  side,  and  unable  to  speak. 

Next  day,  he  was  carried  to  the  ambulance,  and  hemian- 
esthesia was  found  to  exist  in  addition  to  the  hemiplegia.  He 
could  now  speak  with  some  difficulty  and  stammered.  Vision 
and  hearing  were  also  impaired  on  the  left  side.  Reflexes 
weak;  no  sign  of  wound.  There  was  a  convulsive  crisis  of 
some  sort  during  the  day,  and  afterwards  the  man  complained 
of  a  violent  headache,  whereupon  a  lumbar  puncture  showed 
a  clear  fluid  and  a  marked  excess  of  albumin  by  the  heat  test. 

The  following  day,  March  6,  the  patient  had  much  im- 
proved; his  hemiplegia  was  less  marked  and  the  arm  paraly- 
sis had  almost  entirely  disappeared.     He  still  stammered. 

Upon  the  next  day,  vision  and  hearing  were  normal,  and 
the  sensation  was  practically  normal.  A  second  lumbar 
puncture,  March  8,  showed  a  diminution  In  the  amount  of 
albumin,  although  It  was  still  supernormal. 

March  9,  leg  contractured  in  extension;  stammering. 

March  12,  there  was  no  evidence  of  disease.  March  13, 
albumin  was  very  slightly  increased  over  the  normal  in  the 
puncture  fluid.  March  16,  there  was  a  slight  trace  only  of 
weakness  in  the  left  leg.  The  urine  was  throughout  normal. 
The  patient  wrote  Bavo  April  12,  and  May  7  he  was  well  but 
still  felt  heaviness  and  pulling  sensations. 

July  15  it  was  reported  at  Tours  that  he  was  not  yet  well, 
presenting  a  left-sided  hemiparesis,  especially  in  the  leg, 
with  a  syringomyelic  dissociation  of  sensations,  with  atrophy 
of  the  quadriceps  and  diminution  of  reflexes  on  the  left  side. 
The  patient  had  had  a  hematomyelia  (Laignel-Lavastine). 


THE  DIAGNOSIS   OF   SHELL-SHOCK  57 1 


Brachial  monoplegia,  tetanic. 


Case  409.     (RouTiER,  1915.) 

A  soldier  sustained  a  penetrating  wound  of  the  back  of  the 
thorax  on  the  left  side  and  received  an  injection  of  antitetanic 
serum.  A  few  days  later,  May  18,  1915,  he  came  on  hospital 
service  very  sick,  with  high  temperature  and  marked  sup- 
puration. The  next  day  he  had  an  anxious  facies,  tempera- 
ture o.f  40  degrees,  and  sharp  pains  in  the  left  arm.  This 
arm  May  21  was  still  very  painful  and  then  began  to  make 
involuntary  movements  in  the  shape  of  incessant  clonic 
contractions.  The  forearm  would  suddenly  flex  upon  the 
upper  arm,  and  the  upper  arm  itself  would  violently  push  it- 
self forward  and  outward.  Meantime,  the  wrist  and  fingers 
were  not  involved  in  the  contractions.  The  movements  were 
continuous,  but  paroxysmally  increased  in  extent. 

Babinski,  called  in  consultation,  confirmed  the  diagnosis  of 
an  anomalous  form  of  tetanus.  Next  day  trismus,  pleuros- 
thotonos,  and  stiff  neck  developed.  Antitetanic  serum  and 
chloral  had  been  given  from  the  beginning,  with  morphine 
at  night.     The  patient,  however,  died  with  asphyxia  June  3. 

Re  brachial  monoplegia,  the  hysterotraumatic  form  first 
observed  by  Charcot  has  an  anesthesia  with  the  shoulder  of 
mutton  distribution,  slightly  affecting  the  thorax  in  front 
and  behind,  in  addition  to  the  paralysis. 


572  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Paralysis    of    right    leg:     Hysterical?     Organic? 
'*  Micro-organic?  " 


Case  410.     (VoN  Sarbo,  January,   191 5.) 

A  Lieutenant,  aged  28,  lost  consciousness  September  6, 
1 9 14,  as  the  result  of  a  shell  explosion.  When  consciousness 
returned  in  the  hospital,  he  could  not  remember  what  had 
happened.  The  last  he  remembered  was  that  he  had  been 
pushing  forward  with  his  troop.  There  had  been  no  psychic 
shock  whatever.  Examined  September  15,  he  showed  a 
right-sided  hemiplegia  with  stiffness  of  the  right  lower  ex- 
tremity so  that  It  could  not  be  even  passively  flexed.  It  was 
with  difficulty  he  could  walk  and  he  dragged  his  right  foot. 
Patellar  reflex  could  not  be  elicited  on  the  right.  Oppenhelm 
and  BablnskI  were  absent.  There  was  a  slight  nystagmus  on 
looking  to  the  right.  Pupils  normal.  Tongue  deviated  to 
the  left.  Speech  was  slow  and  the  man  had  to  think  a  little 
over  some  expressions.  He  could  not  feel  touch  so  well 
on  the  right  as  on  the  left  and  this  hypesthesia  grew  more 
marked  distally.  He  was  greatly  bothered  because  certain 
words  did  not  come  to  him  readily,  especially  names. 

The  absence  of  the  BablnskI  and  Oppenhelm  reflexes  was 
against  an  organic  hypothesis  and  the  absence  of  hysterical 
stigmata  and  the  non-characteristic  sensory  disorder,  as  well 
as  the  absence  of  any  psychic  shock  In  the  history,  spoke 
against  hysteria.  The  hypoglossus  paralysis  spoke  In  favor 
of  the  organic  nature  of  the  disease. 

According  to  von  Sarbo  we  must  look  for  the  background 
of  so-called  functional  nervous  disorders,  hysteria  and 
neurasthenia,  in  structural  changes  of  the  nervous  system, 
the  changes  that  Charcot  called  molecular.  But  the  lesions, 
he  believes,  do  not  lead  to  a  degeneration  of  neurons.  Ac- 
cordingly we  get  only  the  external  form  of  organic  paralysis 
without  concomitant  symptoms,  such  as  Oppenhelm  and 
BablnskI  reflexes.  Von  Sarbo  terms  his  hypothesis  that  of 
"  microorganic  "  changes.  To  prove  the  hysterical  nature  of 
a  condition  we  must  show  first  that  the  symptoms  have  taken 
their  rise  on  a  mental  or  moral  basis. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  573 


Shell-shock  and  momentary  burial:  Muscular 
weakness,  followed  (third  day)  by  complete  paraly- 
sis (save  neck  and  head).     Diagnostic  hypotheses. 


Case  411.     (Leri,  Froment  and  Mahar,  July,  1915.) 

A  big  shell  burst  October  3,  19 14,  a  little  over  3  meters 
from  a  soldier  crouching  in  a  shallow  Saint  Mihiel  trench. 
The  shell  made  a  hole  two  meters  in  diameter  and  1.5  meters 
deep,  and  covered  the  man  with  loose  earth,  from  which  he 
was  readily  released.  During  the  next  few  days,  the  man 
found  difficulty  in  following  his  comrades  on  short  marches 
(i  to  4  kilometers) .  He  was  unable  to  buckle  on  his  knapsack. 
The  patient  was  himself  not  alarmed  at  his  condition. 

Up  to  the  time  of  his  accident,  this  man,  a  farmer,  had  never 
had  any  motor  trouble,  nor  was  there  any  nervous  disorder 
in  any  of  his  relatives.  He  had  been  in  several  conflicts, 
August  24-25,  September  4-6,  in  the  Argonne  and  in  the 
Haute  Meuse,  and  he  had  never  found  it  hard  to  keep  up  with 
his  comrades.  In  fact,  once  in  the  Haute  Meuse,  he  took  part 
in  an  exceedingly  difficult  and  hasty  retreat,  and  only  a  week 
before  the  shell-shock  above  described  he  had  put  in  a  very 
long  march.  Thus  a  man,  perfectly  normal  before  the  shock, 
had  fallen  into  a  general  state  of  slight  muscular  paralysis. 

On  the  third  day  very  suddenly  this  paralysis  became  com- 
plete. The  wounded  man,  while  sitting  in  the  trench,  found 
that  he  could  not  stand  up  either  with  or  without  the  use  of 
his  hands.  Now,  that  very  morning  he  had  marched  three 
kilometers  from  his  cantonment  to  the  trench.  He  was  sup- 
ported on  the  way  to  the  relief  post,  hardly  200  meters  away, 
and  was  then  sent  to  the  hospital  at  Bar-le-Duc.  At  this 
time  he  was  so  weak  that  he  had  to  be  fed  like  a  child. 

For  a  period  of  three  weeks  he  lay,  unable  to  rise  or  sit  up. 
There  was  one  exception  to  the  generalization  of  the  paresis: 
the  movements  of  the  head  and  neck  were  normal.  A  general 
muscular  atrophy  set  in  during  the  three  months,  but  gradu- 
ally diminished  in  amount.  The  diagnosis  of  myopathy  was 
made,   based  upon   the  evident  degree  of  lumbar  wasting, 


574  THE   DIAGNOSIS   OF   SHELL-SHOCK 

kyphosis,  the  man's  attitude,  gait,  manner  of  rising,  galvano- 
tonic  contractions. 

The  history  was,  of  course,  rather  against  the  diagnosis  of 
myopathy,  as  well  as  the  marked  atrophy  of  the  hands  and 
the  existence  of  an  incomplete  R.  D.  Moreover  the  fact  that 
he  improved  may  be  regarded  as  rendering  the  diagnosis  of 
myopathy  doubtful. 

Other  diagnoses,  less  likely  than  that  of  myopathy,  may 
be  considered,  —  hematomyelia,  recurrent  traumatic  polio- 
myelitis affecting  the  anterior  horns,  polyneuritis. 

Without  making  decision  as  to  the  nature  of  this  case,  Leri 
proposes  the  question  whether  there  is  a  shell-shock  myo- 
pathy and  whether  there  is  a  myopathy  due  to  gas  or  to 
hemorrhage? 


THE  DIAGNOSIS   OF   SHELL-SHOCK  575 


Shell-shock :  Right  hemiplegia  with  contracture  and 
mutism.  Cure  by  isolation  and  suggestion.  Ques- 
tion of  the  relation  between  plantar  areflexia  and  (a) 
anesthesia  (hysterical)  or  (b)  contracture. 


Case  412.     (Dejerine,  February,  1915.) 

A  territorial  infantryman,  36,  of  a  nervous  and  Impres- 
sionable temperament  (father  alcoholic),  was  blown  up  by  a 
bomb  October  3,  1914,  between  Bapaume  and  Arras.  He 
was  evacuated  forthwith  to  the  relief  post.  According  to  his 
own  story,  he  spat  blood,  could  not  talk,  and  felt  his  right 
side  weak.  He  was  three  weeks  at  a  hospital  in  Paimpol, 
with  the  diagnosis  of  right  hemiplegia  with  contracture  and 
mutism.  At  Guingamp,  an  electrical  treatment  was  fol- 
lowed by  a  gradual  disappearance  of  the  arm  contracture. 

Examined  by  Dejerine,  January  2,  1915,  he  was  found 
to  be  a  tall,  stalwart  man  with  right  leg  contractured  in 
extension,  foot  in  equinovarus,  heel  raised.  He  walked, 
dragging  the  leg,  which  trembled;  the  trembling  then  ex- 
tended to  the  rest  of  the  body.  In  dorsal  decubitus,  the 
leg  lay  in  adduction  and  internal  rotation.  He  could  lift 
the  leg  only  5  cm.  above  the  bed,  could  only  slightly  flex  leg 
on  thigh,  and  could  not  at  all  flex  thigh  on  hip.  The  leg 
could  not  be  bent  at  all  if  he  was  requested  to  hold  it  stiff. 
Ankle  joint  movements  were  impossible  from  contracture. 
The  equinovarus  was  in  contracture  which  could  not  be 
corrected.  Right  hip  movements  were  limited  and  painful. 
Muscular  atrophy  absent. 

Whereas  on  the  left  side  plantar  stimulation  produced  not 
only  the  normal  flexor  reflex  but  also  the  classical  defense 
movements  of  flexion  of  leg  on  thigh  and  thigh  on  hip,  — 
on  the  right  side  neither  a  needle  nor  a  match,  nor  any  other 
form  of  stimulation  of  the  sole,  produced  any  kind  of  reac- 
tion on  the  part  of  the  toes,  the  fascia  lata,  or  any  leg  muscles. 
Tested  every  day  for  some  weeks,  the  result  was  always  the 
same.  The  cremasteric  reflex  was  weak  on  the  affected  side. 
Abolition  of  the  plantar  reflex  and  of  the  defense  movements 


576  THE   DIAGNOSIS   OF   SHELL-SHOCK 

on  tlic  right  side  was  associated  with  an  anesthesia  and  a 
hyposthesia  of  the  right  side  of  the  body,  involving  complete 
anesthesia  below  the  knee  and  hypesthesia  of  superficial 
and  deep  sensation  above  the  knee.  The  buccal  and  lingual 
mucous  inenibranes  were  also  hypesthetic.  The  bony  sensi- 
bilit\-  was  lost  in  the  foot  and  lower  leg.  and  was  diminished 
in  all  of  the  bones  of  the  right  side  of  the  body.  There  was  no 
contraction  of  the  visual  helds.  The  right  corneal  reflex  was 
diminished.     There  were  no  other  sensor\-  defects. 

The  man  was  also  aphonic,  being  unable  to  utter  a  word  or 
a  sound  except  a  jerky  whistling  sound  like  the  letting  off 
of  steam.  lie  was  able  to  write  out  his  histon,-  intelligently. 
He  was  \'er\'  emotional,  wept,  and  trembled  all  over  when 
talking  of  wife  and  children.  The  spinal  puncture  fluid  was  in 
all  respects  normal.  A  laryngoscopic  examination  showed 
that  the  vocal  cords  were  functioning  normally.  The  long 
a  could  be  pronounced  distinctly,  at  the  expense  of  great 
effort  so  that  the  larynx  would  finally  be  blocked.  The 
lar\"ngeal  reflex  was  abolished.  The  laryngeal  mucosa  could 
be  touched  with  a  probe  without  producing  the  slightest  pain 
or  coughing  reflex.  By  wa}"  of  treatment,  this  case  of  hys- 
terotraumatism  was  given  Isolation  and  psychotherapy 
for  two  months  without  eft'ect.  But  about  the  middle  of 
March  he  began  to  get  better,  the  s>'mptoms  rapidly  faded, 
cure  was  eft"ected  at  the  end  of  March,  and  the  man  was 
evacuated  to  his  depot. 

Re  reflexes  and  contracture,  see  the  \iews  of  Babinsld  re- 
produced under  Case  3S5  of  Paulian. 


THE   DIAGNOSIS   OF    SHELL-SHOCK  577 


Shell-shock:  Tic  VERSUS  spasm. 


Case  413.     (Meige,  July,  1916.) 

A  soldier  was  bowled  over  in  a  trench  by  a  big  shell  that 
burst  nearby.  He  lost  consciousness  and  was  carried  to  the 
ambulance.  But  he  came  to,  and  was  so  absolutely  well  with 
a  few  hours'  rest  that  he  took  part  in  a  lively  attack  shortly 
thereafter  and  got  a  wound  in  the  left  arm,  affecting  slightly 
the  ulnar  ner\^e.  He  was  sent  to  the  Salpetriere  for  this  ulnar 
nerve  affection,  when  certain  movements  of  his  scalp  were  inci- 
dentally noted. 

The  scalp  movements  were  quick,  affecting  the  fronto- 
occipitalis  muscles  as  w^ell  as  the  auricular  muscles.  The  dis- 
placement was  from  behind  forv\^ard,  and  then  from  before 
backward,  with  slight  oscillations  of  the  ear;  and  at  the  same 
time,  the  forehead  wrinkled  or  became  smooth.  The  move- 
ment was  involuntary  and  more  convulsive  than  the  some- 
what similar  movements  that  many  persons  can  execute  with 
scalp  and  ears.  The  phenomenon  appeared  after  the  shock 
for  the  first  time.  He  had  not  noticed  it  himself  but  the 
physician  at  the  ambulance  had  called  his  attention  to  it. 
The  soldier  was  not  disturbed  by  the  matter,  either  at  that 
time  or  later. 

The  diagnostician  would  consider,  on  the  one  hand,  tic, 
and  on  the  other,  spasm.  According  to  Meige,  the  man  was 
a  victim  of  tic.  No  case  of  such  limited  spasm  appears  to 
have  been  obser\^ed  previously.  However,  the  sudden  devel- 
opment of  these  movements  without  previous  history  of  tic 
renders  the  diagnosis  somewhat  doubtful.  There  was  also  a 
complete  anesthesia  to  pin-prick  in  the  present  case  over  the 
whole  right  side  of  the  scalp,  face,  and  neck,  even  passing 
below  to  involve  the  chest,  shoulder,  back,  and  upper  part 
of  the  right  arm,  with  hypesthesia  decreasing  toward  the 
nipple  and  the  elbow.  The  soldier  was  quite  ignorant  of 
this  sensory  disorder  and  had  never  before  been  examined 
for  sensations.  The  examination  was  made  with  due  pre- 
cautions to  avoid  suggestion.     The  question  of  anastomosis 


578  THE  DIAGNOSIS   OF   SHELL-SHOCK 

between  the  facial  nerve  and  the  auriculo-temporal  branch 
of  the  trigeminus  and  the  auricular  branch  of  the  cervical 
plexus,  and  of  their  relations  to  the  anesthesia  and  tic  of  this 
case,  is  raised. 

Re  pathological  movements  such  as  tremors,  tics,  and 
choreiform  movements,  Roussy  and  Lhermitte  divide  the 
tremors  (see  also  under  Case  337)  into  typical  and  atypical. 

The  atypical  ones  are  either  limited,  or  more  usually 
generalized  when  they  are  merely  parts  of  the  Shell-shock 
syndrome.  Sometimes  the  tremors  are  paroxysmal,  aggra- 
vated by  noises.  Now  and  then,  a  condition  of  tremophobia 
appears  (see  Case  225).  As  for  the  typical  tremors,  see 
classifications  under  Case  337. 

Re  tics,  the  tonic  or  postural  tic  is,  according  to  Roussy 
and  Lhermitte,  much  less  common  than  clonic  or  spasmodic 
movements,  which  are  Shell-shock  phenomena  like  tremors 
and  usually  yield  to  psychotherapy  if  treated  early.  These 
tics  are  usually  observed  in  and  about  the  head,  involving 
the  stemomastoid,  trapezius,  and  platysma  muscles  to  pro- 
duce clonic  contractions  of  the  neck.  Other  tics  involve 
coarser  head  movements,  nodding,  eyelid  and  facial  spasms, 
bilateral  or  unilateral,  and  shoulder  movements.  Babinski 
has  suggested  that  some  of  the  tremors  are  possibly  due  to 
organic  disease,  in  view  of  the  fact  that  they  are  not  readily 
influenced  by  psychotherapy.  Meige  has  suggested  that 
some  of  the  tics  may  also  be  in  some  sense  organic.  As  for 
the  differential  diagnosis  of  tremor  and  tic,  according  to 
Roussy  and  Lhermitte,  the  Shell-shock  onset  may  be  an  indi- 
cator. The  non-rhythmic  and  irregular  nature  of  the  tic 
movements,  and  their  exaggeration  on  voluntary  movement, 
may  be  of  some  importance.  Most  of  the  tremors  appear 
to  be  attended  by  a  certain  degree  of  permanent  contraction 
of  the  muscle  groups  concerned.  Tremors  cease  when  these 
contractions  disappear. 

A  point  in  treatment  is  that  complete  muscular  relaxation 
should  be  obtained  by  having  the  patient  open  his  mouth  and 
breathe  deeply. 

Re  diagnosis  of  neurasthenia  in  this  case,  It  may  be 
inquired  whether  the  term  is  properly  used,   and  whether 


THE   DIAGNOSIS   OF   SHELL-SHOCK  579 

there  is  not  some  confusion  here  betwixt  neurasthenia  and 
hysteria. 

Re  hyperalgesia,  Myers  states  that  about  25  per  cent  of 
his  Shell-shock  cases  have  shown  a  variety  of  disorders  of 
the  skin  sense.  Hyperesthesia  and  over-reaction  is  one  phe- 
nomenon in  the  list,  but  is  far  less  common  than  hyperes- 
thesia. According  to  Myers,  the  hyperesthesia  was  more 
relative  than  absolute,  and  was  probably  due  to  increased 
affective  response. 


580  THE    DIAGNOSIS   OF   SHELL-SHOCK 


Shell-shock;     unconsciousness:     Tremors,     anes- 
thesias.    Recovery  by  suggestion. 


Case  414.     (MoTT,  January,  1916.) 

August,  191 5,  between  Ypres  and  Flamentieres,  a  Jack 
Johnson  exploded  one  day  about  three  o'clock  in  the  morn- 
ing near  an  experienced  gunner,  who  had  been  on  service  in  the 
R.  F.  A.  for  15  years,  and  in  France  during  the  present  war 
10  months.  He  came  to  in  the  military  hospital  at  Chatham, 
two  weeks  later,  and  was  told  he  was  lucky  to  be  there  at  all 
as  the  shell  had  killed  many  comrades.  He  was  transferred 
to  Colchester,  and  thence  to  the  Fourth  London  General 
Hospital. 

Sitting  in  a  chair,  the  man  showed  continuous  rhythmic 
movements  of  legs,  hands,  and  jaw,  exaggerated  when  he  was 
spoken  to.  The  tremor  was  almost  a  clonic  spasm.  Every 
now  and  then,  the  patient  would  start  and  look  sidewise  and 
upwards,  as  if  a  shell  were  about  to  drop.  Hyperacusis  was 
such  that  the  firing  of  the  guns  as  far  off  as  Woolwich  alarmed 
him.  In  telling  his  story,  he  would  repeat  the  same  words 
over  and  over.  He  dreamt  of  shells  bursting.  His  sleep  was 
disturbed  with  groaning  and  moaning.  The  face  was  flushed, 
and  the  palms  sweating.  Because  of  the  constant  tremor,  he 
could  not  stand  or  walk  without  assistance,  and  it  was  diffi- 
cult to  test  reflexes.  The  tremor  somewhat  resembled  the 
intention  tremor  of  multiple  sclerosis.  He  was  unable  to 
feel  the  prick  of  the  needle  on  legs,  left  arm,  or  hand.  He 
could  not  feel  vibrations  of  the  tuning-fork  on  feet,  legs,  or 
hands,  though  he  could  on  the  forehead.  The  fork  was 
heard  quite  well  six  inches  from  the  ears.  There  was  some 
difficulty  in  recognizing  colors.  Bitter  fluids  could  be  tasted, 
but  vinegar,  salt,  and  various  fluids,  could  not  be  recognized. 
He  could  not  recognize  tincture  of  assafetida,  attar  of  roses, 
or  oil  of  cloves,  though  nitrite  of  amyl,  ammonia  and  glacial 
acetic  acid  were  recognized. 

Major  Mott  felt  that,  though  this  prolonged  severe  disease 
in  a  long-service  man  might  possibly  be  related  to  some  or- 


THE  DIAGNOSIS   OF   SHELL-SHOCK  58 1 

ganic  change  in  the  brain,  he  might  well  treat  him  by  sugges- 
tion. Major  Mott  told  him  that  the  careful  examination 
just  made  showed  that  there  was  no  organic  disease,  and  made 
it  certain  that  he  would  recover.  In  a  fortnight,  he  sat  in  a 
chair  without  tremors  and  with  a  profound  belief  in  Major 
Mott. 


582  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Hysteria  as  appendix  to  traumata. 


Case  415.     (MacCurdy,  July,  1917.) 

A  private,  25,  something  of  a  liar  and  of  rather  a  low  per- 
sonality, had  enlisted  in  the  regular  army  in  191 1,  but  de- 
serted to  become  a  football  player.  He  reenlisted,  and  went 
to  France  in  September,  1914,  enjoying  the  first  six  months. 
He  broke  his  ankles  by  falling  into  a  deep  dug-out,  and  got 
frost-bite.  After  three  or  four  months  in  England,  he  found 
that  he  did  not  wish  to  go  back  to  France.  He  was  two 
months  in  barracks,  and  then  went  up  the  line  in  a  good  deal 
of  a  panic.  Soon  after,  he  was  wounded  in  the  thigh  and  was 
able  to  remain  in  hospital  a  fortnight,  exposed,  however,  to 
shell- fire  and  given  to  starting  at  noise  and  occasional  war 
dreams.  Sent  to  his  base,  he  remained  jumpy  and  was  now 
permanently  afraid  of  the  line.  After  three  weeks  in  the 
trenches,  he  again  got  wounds,  spent  five  months  in  England, 
came  back  to  France  in  May,  and  fought  till  September,  191 6. 
He  tried  to  convince  the  medical  officer  that  he  had  appen- 
dicitis and  trench  fever. 

About  the  middle  of  September  he  saw  with  horror  a  man 
crushed  by  a  tank,  and  thereafter  was  markedly  affected  by 
the  sight  of  blood.  Another  slight  wound  sent  him  to  a  rest 
camp  for  two  weeks,  whence  he  was  again  thrown  into  the 
line,  suffering  acutely  from  fear  and  horror  of  blood.  In 
three  days  he  fractured  his  left  collarbone  and  wrist.  He  gave 
a  pint  and  a  half  of  blood  for  transfusion  purposes,  and  in 
turn  was  shipped  to  England.  On  removal  of  the  splint,  he 
found  "  probably  not  without  satisfaction  "  that  the  arm 
was  paralyzed.  It  remained  paralyzed  for  five  months,  until 
treatment  in  a  special  hospital  eventually  cured  the  arm; 
but  upon  cure  of  the  arm,  nightmares  developed,  —  an  in- 
dication, according  to  IVIacCurdy,  of  the  strong  resistance  he 
felt  to  the  idea  of  returning  to  the  front. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  583 


Neurasthenic  hyperalgesia  after  peripheral  nerve 
injury. 


Case  416.     (Weygandt,  January,  1915.) 

A  German  volunteer,  a  sportsman,  was  under  heavy  shell 
fire  after  the  middle  of  October,  19 14,  and  was  wounded  in 
the  upper  arm  in  November,  with  an  injury  to  the  median 
nerve  that  occasioned  severe  pain.  These  strictly  localized 
pains  increased  upon  any  sort  of  physical  or  mental  strain. 
If  he  walked  down  steps  he  kept  thinking  he  might  have  an 
accident,  and  then  the  pains  set  in  with  greater  force.  He 
became  apathetic  so  that  he  did  not  eat,  drink  or  urinate. 
If  his  head  were  touched  he  felt  pain  as  if  from  an  electric 
shock.  He  also  felt  the  pain  when  he  saw  anybody  approach- 
ing a  door  to  close  it,  through  apprehension  of  the  noise. 
Meantime,  the  wound  was  well  healed.  The  pulse  was  ac- 
celerated. The  visual  fields  were  only  slightly  contracted. 
The  patient  wanted  to  get  well  and  go  back  to  the  service. 

Weygandt  regards  this  hyperalgesia  after  peripheral  nerve 
injuries  as  neurasthenic. 


584  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Military    training:     Peripheral    neuritis    in    lead 
workers. 


Case  417.     (Shufflebotham,  April,  1915.) 

Among  fourteen  cases  of  lead  poisoning,  members  of  the 
territorial  forces,  largely  from  North  Staffordshire,  was  a 
patient  suffering  from  peripheral  neuritis.  He  had  been  in 
the  dipping-house.  Two  years  before  going  into  the  service 
he  had  been  suspended  for  lead  poisoning  by  the  factory 
surgeon.  Giving  up  his  work  at  the  pottery,  he  became  a 
general  laborer  in  a  non-lead  process  factory. 

Three  weeks  after  enlistment,  the  man  began  to  complain 
of  pains,  tenderness  in  the  arms,  weakness  of  the  wrists, 
headache,  giddiness,  nausea,  and  constipation.  The  bowels 
were  opened  by  a  large  dose  of  epsom  salts.  On  blood  exam- 
ination the  hemoglobin  was  found  diminished  40  per  cent; 
cells  with  basophilic  granules  w^ere  found  to  the  number  of 
500  per  cu.  mm.  The  face  was  characteristically  pasty. 
There  was  albuminuria.  Alcohol  could  be  excluded.  The 
man  had  to  be  discharged. 

All  Shufflebotham's  cases  occurred  from  three  to  seven 
weeks  after  mobilization,  nor  have  any  cases  ever  been  re- 
ported in  territorials  after  their  annual  training.  Con- 
stipation was  invariable.  In  two  cases  returned  to  service, 
there  was  a  recurrent  attack.  An  epidemic  could  be  ex- 
cluded. Shufflebotham  suggests  that  the  altered  conditions 
of  life,  especially  the  marching  and  drilling,  caused  increased 
metabolism,  setting  free  lead  compounds  from  the  muscles 
and  organs  of  the  body.  It  is  true  that  a  glost  placer  always 
works  very  hard  with  his  muscles,  but  not  with  the  muscles 
used  by  the  soldier. 


THE  DIAGNOSIS   OF  SHELL-SHOCK  585 


'*  Peripheral  neuritis  "  cured  by  faradism. 


Case  418.     (Cargill,  February,  1916.) 

A  Naval  Service  man,  20,  was  thought  to  have  peripheral 
neuritis.  A  long  history  of  pain  and  numbness  in  arms  and 
legs,  a  well-marked  analgesia  and  anesthesia  over  the  anterior 
aspects  of  forearms  and  legs,  and  an  anesthetic  band  across 
the  front  of  the  chest,  seemed  consistent  with  the  diagnosis. 
The  calf  muscles  tightly  squeezed  yielded  no  pain.  Pins 
could  be  thrust  without  pain  into  the  anesthetic  areas.  When 
told  to  say  yes  when  the  pin  was  felt,  and  no  when  it  was  not 
felt,  the  man  persistently  said  no  when  the  areas  noted 
above  were  touched.  The  deep  reflexes  were  normal.  Fara- 
dism by  wire  brush  at  two  sittings  yielded  a  complete  cure. 
It  seems  that  once  this  man,  after  seeing  his  sister  fall  in  a 
fit  on  returning  from  a  funeral,  retired  to  the  garden  and  had 
a  similar  fit  himself. 

Cargill  found  in  1052  sailors  fifteen  cases  of  total  absence 
of  one  or  both  ankle- jerks;  seven  of  the  fifteen  were  probably 
cases  of  tabes. 

Re  peripheral  neuritis  and  hysteria  (see  under  Case  387). 

Re  differential  diagnosis  between  peripheral  neuritis  and 
reflex  (physiopathic)  paralysis,  Babinski  and  Froment  offer 
the  following  table : 

Peripheral  Neuritis.  Reflex  Paralysis  and  Contracture 

1.  Motor  disorder,  degenerative  amy-      i.    More    or    less    segmentary    topog- 

otrophy,    and    sensory    disorder  raphy. 

corresponding  topographically  to 
anatomical  distribution  of  nerve 
(neuritic)  topography. 

2.  Amyotrophy  very  pronounced,   re-      2.   Amyotrophy    variable;     ordinarily 

gardless  of  localization.  well-marked  but  not  so  severe  as 

that  of  neuritis. 

3.  Reaction  of  degeneration,  especially      3.    Reaction    of    degeneration   absent, 

weakening  or  abolition  of  faradic  never  marked  weakening  of  fara- 

excitability  of  muscles.  die   excitability,   which   is   often 

normal  and  may  even  be  exag- 
gerated. 

4.  Tendon  reflexes,  corresponding   to      4.    If  reflexes  are  altered,  they  are  as  a 

the    muscular    territory    of    the  rule  exaggerated  and  never  abol- 

nerve,  weakened  or  abolished.  ished. 


586  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Multiple  wounds;  signs  of  late  tetanus  7-8  weeks 
later:  Pain  and  contracture  of  neck,  tetanic,  14 
weeks  after  trauma.     Dysentery.     Recovery. 


Case  419.     (Bouquet,  1916.) 

A  soldier  invalided  for  endocarditis  July  8,  1908,  went 
back  to  the  colors  on  his  own  request  August  8,  191 4.  He  was 
wounded  at  noon  September  6,  1 914,  in  the  attack  at  Abbaye 
Woods.  He  lay  in  the  woods,  with  several  comrades  as 
badly  wounded  as  himself,  until  September  10,  eating  berries 
and  drinking  rain  water.  He  had  five  wounds  in  all;  in 
left  lower  leg,  thigh,  left  external  malleolus,  right  calf,  and 
left  forearm.     Moreover,  he  had  dysentery. 

He  was  picked  up  by  the  Germans  September  10  and 
carried  by  them  to  the  ambulance  at  Saint  Andre,  where  he 
was  given  belated  first  dressing.  When  the  enemy  retreated 
September  12  he  was  left  behind  and  finally  carried  back 
September  13  into  the  French  lines  by  a  French  physician 
who  had  been  a  prisoner  likewise.  A  second  dressing  was 
given  September  14  at  Rambluzin.  He  was  then  carried  in  a 
sanitary  train  to  Bar-sur-Aube,  where,  September  15,  in- 
jection of  anti tetanic  serum  was  given.  He  left  Bar-sur- 
Aube  on  December  18,  1914,  practically  cured,  though  one 
of  the  wounds  still  needed  care.  The  dysentery  was  still 
present  and  walking  was  difficult.  He  was  then  cared  for 
at  Auxiliary  Hospital  No.  102  in  Paris. 

It  seems  that  about  six  weeks  after  his  entrance  in  the 
hospital  at  Bar-sur-Aube  he  had  had  some  difficulty  in 
opening  his  jaws,  with  acute  pains  at  the  temporomaxillary 
joint.  Similar  pains  appeared  a  few  days  later  in  the  neck, 
with  a  sensation  of  stiffening.  The  jaws  still  opened  easily 
enough  December  18,  yet  the  man  got  pains  in  his  jaws^as  soon 
as  he  began  to  speak.  The  pain  and  contracture  in  the  neck 
region  were  sharp  and  permanent.  Sometimes  the  con- 
tracture got  more  marked,  and  the  board-like  muscles  could 
be  felt  stiffening  under  the  examining  finger.  During  such 
crises  the  patient  had  to  lie  or  sit  down.     Sometimes  the 


THE  DIAGNOSIS   OF   SHELL-SHOCK  587 

pains  descended  below  the  shoulders  along  the  vertebral 
column.  The  crises  occurred  more  often  in  the  night,  in  bed. 
The  diagnosis  of  late  tetanus  was  made,  and  alcohol  rubs 
were  given.  The  phenomena  gradually  disappeared.  The 
dysentery  also  had  not  yielded  to  therapeutics  until  eight  or 
ten  days  before  the  patient  left  the  hospital.  There  was 
still,  at  the  time  of  report,  a  certain  difficulty  in  walking,  with 
a  tendency  to  use  the  external  border  of  the  left  foot  rather 
than  the  sole. 


;88  THE   DIAGNOSIS   OF    SHELL-SHOCK 


Shell-shock:     Spasmodic     neurosis     and     neuras- 
thenia.    Treatment  without  great  success. 


Case  420.     (Oppenheim,  July,  1915.) 

August  19,  1914,  a  shell  exploded  very  close  to  a  soldier, 
whose  bread  bag,  cartridge  container,  and  field  flask  were 
pulled  away  from  him,  but  who  was  not  himself  wounded. 
He  fell  down.  Shortly  developed  headache,  vertigo,  palpi- 
tation. In  running  he  fell  down  repeatedly.  Spasms  soon 
appeared  in  the  legs.  He  had  previously  suffered  from  gas- 
tric disturbances,  and  heavy  food  did  not  agree  with  him. 

At  the  time  of  admission  to  hospital  he  complained  of  great 
irritability,  nervous  twitching,  formication  in  his  limbs,  war 
dreams,  tachycardia.  The  heart  boundaries  were  normal. 
The  muscles  of  lower  extremities  were  attacked  by  tonic 
spasms,  and  felt  board-like.  This  tonic  spasm  occurred  on 
each  attempt  at  motion,  very  gradually  disappearing  when  at 
rest.  Passive  movements  also  had  the  same  effect.  Fibril- 
lary tremor  affected  the  left  quadriceps.  On  each  attempt  at 
motion,  pains  were  felt  in  the  legs.  At  first  the  cramps  were 
so  severe  that  all  locomotion  or  even  standing  was  impossible. 

Treatment:  Cold-water  pack  (Priessnitz),  hyoscin  in- 
jections, magnesium  sulphate  injections  (5  to  10  c.c.  of 
ten  per  cent  solution),  perineural  injections,  umbar  spinal 
analgesia,  —  all  without  success.  Fibrillary  tremors  per- 
sisted in  the  quadriceps  and  In  the  extensors  of  the  toes.  The 
tonic  spasms  on  increased  attempts  at  motion  became  com- 
bined with  clonic  twitchings.  From  the  end  of  November 
on  the  patient  made  attempts  to  walk  with  straddling  legs, 
and  under  considerable  vibratory  tremor.  Picture  of  severe 
crampus-neurosis,  combined  with  neurasthenia  gravis. 


THE  DIAGNOSIS  OF   SHELL-SHOCK  589 


SHELL   CONCUSSION 

Cause  physical  from  explosives  —  amnesia  for  shell  episode 
and  for  a  subsequent  period  —  followed  by  traumatic 
neurosis 


SHELL  HYSTERIA 

Shell  heard  —  victims  already  unstable  —  rum  issue  prepar- 
atory? —  overemotionalism  —  sensory  and  motor  disorder 


SHELL  NEURASTHENIA 

Headache,    dizziness,    insomnia,    anorexia,    visceral     pain 
victims,  older  men 


After  H.  P.  Wright 


Chart  13 


590  THE   DIAGNOSIS   OF   SHELL-SHOCK 


(a)  Bullet- wound  of  forearm:  Combination  of  hys- 
terical (brachial)  monoplegia,  and  reflex  (physio- 
pathic)  disorders,  (b)  Refrigeration:  Combination 
of  hysterical  paraplegia  and  reflex  (physiopathic) 
disorders. 


Case  421.     (Babinski,  1916.) 

The  forearm  of  a  soldier  was  pierced  in  its  lower  part  by  a 
bullet,  which  produced  no  lesion  of  large  nerve  trunks  or 
blood  vessels.  A  complete  brachial  monoplegia  followed. 
Every  movement  of  the  different  segments  of  the  arm  was 
abolished.  The  hand  and  forearm  were  slightly  atrophied, 
and  were  of  a  reddish  salmon  color.  The  temperature  of  the 
affected  hand  and  forearm  was  about  three  or  four  degrees 
lower  than  that  on  the  other  side.  The  sphygmometric  os- 
cillations of  the  forearm  were  twice  as  small  in  the  paralyzed 
limb  as  in  the  healthy  limb,  but  the  systolic  blood  pressure 
was  normal.  There  was  a  mechanical  over-excitability  of 
the  muscles,  and  a  slight  exaggerat  on  of  the  bone  and  ten- 
don reflexes.  The  paralysis  was  in  part  of  reflex  (physio- 
pathic) nature.  On  account  however,  of  the  completeness  of 
the  monoplegia,  and  the  fact  that  the  reflex  paralyses  as  a 
rule  affect  only  the  distal  portion  of  the  limb,  the  diagnosis 
of  hysteria  had  to  be  made  in  addition  to  the  diagnosis  of 
reflex  disorder. 

As  a  result  of  freezing,  this  patient  had  also  a  complete 
crural  paraplegia.  He  showed  vasomotor  disorders  and  hy- 
pothermia of  both  feet,  together  with  mechanical  over- 
excitability  of  the  muscles;  and  these  latter  disorders  ap- 
peared to  be  of  a  reflex  nature.  The  paraplegia,  however, 
was  of  a  hysterical  nature. 

Re  refrigeration,  see  Case  309  (Binswanger)  of  glossolabial 
spasm. 


THE  DIAGNOSIS   OF   SHELL-SHOCK 


591 


Differential  diagnosis  of  organic  (central)  monoplegia  and 
reflex  (physiopathic)  contracture  and  paralysis.  (Babinski- 
Froment.) 


Organic  Monoplegia 

Paralysis   often   affects   the   whole 
extremity,  either  arm  or  leg. 


2.   After  several  weeks  of  flaccid  paraly- 
sis, as  a  rule  contracture  occurs. 


3.  The  upper  extremity  shows  flexion      3. 

with  clawhand.  The  lower  ex- 
tremity shows  contracture  of 
extensors.  The  patient  walks 
throwing  his  leg  sidewise  {De- 
marche helicopode). 

4.  Tendon  reflexes,  a  few  weeks  after      4. 

paralysis  begins,  exaggerated. 

5.  Babinski  sign  in  crural  monoplegia.      5. 


Reflex  Contracture  and  Paralysis 

Paralysis  almost  always  partial. 
In  arm  paralysis,  affects  as  a  rule, 
fingers  and  hand.  The  leg  is 
often  affected  at  its  origin,  and 
then  only  partially. 

Paralysis  may  remain  flaccid  for  a 
long  time,  and  frequently  co- 
exists with  contracture,  hyper- 
tonicity  and  hypotonicity  of 
different  muscular  groups. 

The  upper  extremity  in  hypertonic 
cases  often  shows  the  main  d'ac- 
coucheur,  the  main  en  benitier 
(holy-water- vessel  hand),  the 
doigts  en  tuile  (crowded  fingers). 
The  lower  extremity  does  not 
exhibit  the  sidewise  movements. 

Reflex  status  variable.  Hyper- 
reflexia  often  absent  even  in 
hypertonic  forms. 

Babinski  sign  absent.  The  skin  re- 
flex may  be  abolished  but  may  be 
reproduced  on  warming  the  foot. 


592  THE   DIAGNOSIS   OF    SHELL-SHOCK 


Slight  bullet  wound  of  hand :  Flaccid  paralysis  with 
vasomotor  and  thermic  disorder.  A  case  "  non- 
organic "  in  the  ordinary  sense  and  non-hysterical, 
i.  e.,  reflex  or  physiopathic. 


Case  422.     (Babinski  and  Froment,  191 7.) 

Struck  by  his  observations  upon  the  persistence  of  tendon 
reflexes  in  narcosis  in  a  wounded  soldier,  Babinski  continued 
observations  in  the  same  general  direction  in  a  case  which 
may  be  termed  briefly  one  of  hypotonia  of  the  extensors  of 
the  hand  following  the  passage  of  a  bullet  through  the  arm 
without  nerve  trunk  lesion. 

This  patient  had  flaccid  paralysis  of  hand  and  fingers  fol- 
lowing wound  In  second  dorsal  Interosseous  space  and  vaso- 
motor disorder  and  local  hypothermia  In  the  hand.  There  was 
a  slight  diffuse  atrophy  of  the  muscles  of  the  hand,  forearm, 
and  arm;  but  this  atrophy  was  not  systematized,  and  there 
was  no  R.  D.  The  tendon  reflexes  of  the  extremity  were 
preserved.  There  were  no  signs  of  organic  disease  of  the 
central  or  peripheral  nervous  system ;  that  Is,  In  the  ordinary 
sense  of  these  terms. 

Was  it  a  question  of  hysteria  or  of  simulation? 

Babinski  was  struck  by  the  following  symptoms: 

First,  the  remarkably  intense  hypotonia,  especially  note- 
worthy in  the  thumb,  a  hypotonia  quite  equal  if  not  supe- 
rior to  that  observed  In  paralysis  following  marked  nerve 
lesions ; 

Second,  mechanical  over-excitability  of  high  degree  In  the 
muscles  of  the  hand  and  forearm,  with  retardation  of  the 
muscular  response;  and 

Third,  electric  over-excitability  of  the  muscles,  with  what 
Babinski  calls  "  anticipated  fusion  "  of  the  faradic  reactions. 

It  appears  that  this  patient  had  been  wounded  In  Sep- 
tember, 1 914,  and  that  the  paralysis  had  developed  five 
months  later.  Before  the  development  of  this  paralysis, 
there  had  been  simply  a  melopragic  state. 

Without  perforating  the  hand,  the  bullet  had  remained 


THE   DIAGNOSIS   OF   SHELL-SHOCK  593 

in  the  wound,  being  excised  tlierefrom  three  months  after 
the  trauma. 

In  January,  1916,  —  that  is,  some  sixteen  months  after 
the  injury  and  eleven  months  after  the  recovery  of  the  paral- 
ysis,—  the  vasomotor  disorder  and  the  hypothermia,  and 
the  faradic,  voltaic  and  mechanical  over-excitability  of  the 
hand  and  forearm  muscles,  were  in  evidence.  Hypotonia 
was  marked,  permitting  an  overflexion  of  the  hand  upon  the 
forearm.  If  the  patient  moved  his  forearm,  the  affected 
hand  would  hang  and  oscillate  inertly;  likewise  in  walking, 
seeming  to  obey  only  the  laws  of  physics. 

In  May,  191 6,  the  patient  was  invalided  and  found  to  be 
still  in  possession  of  the  above-mentioned  signs.  Similar 
phenomena  have  been  found  in  the  mainfigee  acrocontracture, 
and  main  d' accoucheur ,  and  belong,  in  the  opinion  of  Babin- 
ski,  to  a  group  which  is  neither  hysterical  nor  organic  in  the 
ordinary  sense  of  the  terms.  Vasomotor  and  thermic  phe- 
nomena are  in  the  foreground  of  the  picture, and  are,  in  fact, 
practically  constant,  though  they  vary  somewhat  in  degree. 
They  react  abnormally  to  the  temperature  of  the  surround- 
ing medium;  there  is  undoubtedly  a  local  perturbation  of 
the  vasomotor  and  heat-regulating  mechanism.  There  is 
also  certain  evidence  of  vascular  spasm.  The  vasomotor  and 
thermic  disorders  run  parallel  with  the  mechanical  over- 
excitability  of  the  muscles  and  the  slowness  of  the  response. 


594  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Chloroform  to  demonstrate  asymmetry  of  reflexes. 


Case  423.  (Babinski  and  Froment,  191 7.) 
A  soldier,  26,  sustained,  September  22,  1914,  a  bullet  in- 
jury of  the  right  calf.  There  was  no  fracture,  as  X-ray 
showed,  but  healing  was  slow,  taking  no  less  than  three 
months.  The  right  knee-jerk  was  a  little  stronger  and  a 
little  sharper  than  the  left,  but  the  difference  was  contro- 
versial; and  the  difference  between  the  two  Achilles  re- 
flexes was  still  more  doubtful. 

Chloroformed  October  10,  191 5:  As  the  patient  was  going 
to  sleep,  even  before  the  phase  of  excitation  and  motor  agi- 
tation had  passed,  the  two  knee-jerks  and  left  Achilles  jerk 
had  disappeared.  They  grew  rapidly  less  marked  before 
disappearing,  and  none  of  the  tendon  reflexes  presented  any 
phase  of  exaggeration  while  the  patient  was  going  under. 
At  this  point  anesthesia  was  arrested.  The  right  Achilles 
reflex,  which  had  not  disappeared,  was  sharply  defined.  It 
was  even  stronger  than  in  the  normal  state  and  polykinetic. 
During  the  whole  phase  of  awaking  from  the  chloroform,  the 
right  Achilles  reflex  remained  strong  and  polykinetic,  without, 
however,  any  ankle  clonus.  Thus,  the  difference  between 
the  two  Achilles  reflexes  became  indisputable;  also  the  right 
knee-jerk  reappeared  before  the  left,  and  became  stronger 
without  any  patellar  clonus.  At  this  time,  the  difference 
between  the  two  knee-jerks  was  sharp  and  beyond  cavil. 
This  status,  in  which  the  knee-jerk  and  Achilles  reflexes  were 
asymmetrical,  lasted  about  ten  minutes  after  anesthesia 
ceased  and  lasted  a  little  longer  for  the  knee-jerks  than  for 
the  Achilles  jerks. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  595 


Reflexes  under  chloroform. 


Case  424.  (Babinski  and  Froment,  October,  191 5.) 
A  soldier  sustained  a  clean-cut  wound  of  the  supero-ex- 
ternal  aspect  of  the  right  thigh  without  much  destruction 
of  tissue  or  any  adherent  scar.  He  showed  marked  lameness, 
September  15,  191 5,  walking  with  his  right  leg  extended  and 
the  foot  in  external  rotation.  There  was  a  slight  limitation 
of  the  movements  of  the  hip  joint  in  respect  to  internal  ro- 
tation and  flexion  of  thigh.  The  right  knee-jerk  was  a  little 
stronger  than  the  left,  and  this  condition  persisted  several 
days.  After  a  few  tests,  the  knee-jerk  became  even  slightly 
polykinetic.  The  Achilles  jerks  were  normal  and  equal. 
There  was  no  epileptoid  trepidation  of  the  foot,  and  no  pa- 
tella clonus.  There  was  a  slight  hypothermia  of  right  leg, 
with  ill-defined  muscular  atrophy.     Walking  caused  pain. 

Chloroform  anesthesia,  September  20,  191 5,  yielded  an 
exaggeration  of  the  knee-jerks  with  a  suggestion  of  patella 
clonus  even  before  the  phase  in  anesthesia  of  motor  excitation 
had  set  in.  As  anesthesia  proceeded  the  exaggeration  was 
rapidly  lost  on  the  left  side  but  progressively  increased  on 
the  right.  In  the  phase  of  complete  muscular  resolution, 
when  all  the  other  tendon  reflexes  (such  as  the  knee-jerk, 
Achilles  jerk  on  the  left  side,  the  radial  and  olecranon  re- 
flexes on  the  left  side)  were  abolished,  the  patella  clonus  on 
the  right  side  was  perfectly  distinct  and  could  be  elicited 
either  by  the  usual  method  or  by  raising  the  thigh  and  letting 
it  fall.  On  percussion  of  the  patella  tendon,  a  strong  poly- 
kinetic reflex  was  obtained;  right  Achilles  jerk  preserved; 
right  leg  in  external  rotation.  Internal  rotation  could  be 
passively  performed  better  than  in  the  waking  state,  but 
this  movement  was  still  limited.  As  the  man  was  waking 
from  anesthesia,  when  reflexes  were  reappearing,  there  was 
a  suggestion  of  left  patella  clonus  —  right  clonus  as  strong  as 
before.  At  no  time  any  trepidation  of  the  foot.  The  patella 
clonus  on  the  right  side  lasted  an  hour  after  waking,  at  which 
time  all  the  reflexes  returned  to  their  previous  state. 


596  THE   DIAGNOSIS   OF    SHELL-SHOCK 


Reflexes  under  chloroform. 


Case  425.  (Babinski  and  Froment,  October,  191 5.) 
A  soldier  sustained  a  bullet  wound,  September  22,  1914, 
in  the  right  calf.  There  was  no  fracture,  as  X-ray  showed. 
Cicatrization  was  slow  and  took  at  least  three  months.  He 
was  examined  October  2,  191 5,  at  the  Pitie,  —  not  complain- 
ing of  pains,  but  lame.  There  were  no  pains,  limitation  of 
movement,  or  joint  sounds  in  the  hip  joint,  and  X-ray  was 
negative.  There  was  a  slight  atrophy  of  the  limb,  1.5  cm. 
less  in  circumference  on  the  right.  There  was  a  sharply  de- 
fined local  hypothermia  of  the  right  leg  up  to  the  knee.  The 
right  knee-jerk  was  a  little  stronger  and  brisker  than  the 
left,  yet  it  was  difficult  to  be  sure  of  this,  and  there  was  a 
still  more  doubtful  difference  between  the  Achilles  reflexes. 

The  man  was  anesthetized  with  chloroform,  October  10, 
As  he  was  going  to  sleep,  before  the  phase  of  excitement  and 
agitation  had  ceased,  the  two  knee-jerks  had  disappeared. 
At  the  same  time,  the  left  Achilles  jerk  vanished,  followed  by 
the  plantar  cutaneous  reflexes.  Anesthesia  was  then  stopped. 
The  right  Achilles  jerk,  which  had  not  disappeared  at  any 
time,  remained  distinct.  It  was  stronger  than  in  the  waking 
state,  and  polykinetic.  During  the  waking  phase,  this  reflex 
remained  strong  and  polykinetic,  but  there  was  no  epilep- 
toid  trepidation  of  the  foot.  Accordingly,  under  chloroform, 
the  difference  of  the  two  Achilles  reflexes  had  become  very 
sharp.  The  right  knee-jerk  reappeared  before  the  left  and 
became  stronger,  though  without  patella  clonus.  This  dif- 
ference was  much  more  striking  than  in  the  waking  state. 
This  asymmetry  of  the  patella  and  Achilles  reflexes  lasted 
about  10  minutes  after  anesthesia  was  stopped,  and  lasted 
a  little  longer  for  the  patella  reflexes  than  for  the  Achilles 
reflexes. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  597 


Shrapnel  wound  above   clavicle :  Brachial  mono- 
plegia, partly  hysterical,  partly  organic. 


Case  426.  (Babinski  and  Froment,  1916.) 
Babinski  speaks  of  certain  symptomatic  incompatibilities 
which  emerged  in  the  study  of  cases  of  combinations  of 
hysteria,  organic  nervous  disease,  and  the  so-called  physio- 
pathic  disorders.  An  example  of  such  an  incompatibility 
might  be  that  of  a  patient  who  should,  three  months  after  a 
sudden  hemiplegia,  show  complete  or  almost  complete  flaccid 
paralysis  and  but  slight  exaggeration  of  tendon  reflexes  — 
yet  the  Babinski  reflex.  Of  course,  the  Babinski  reflex  would 
permit  a  diagnosis  of  pyramidal  tract  disease.  Yet  a  sudden 
intense  hemiplegia  lasting  three  months,  if  it  were  merely 
a  matter  of  pyramidal  tract  disorder,  ought  to  show  hyper- 
reflexia  of  a  pronounced  degree  as  well  as  contracture.  An 
example  from  the  arm  is  as  follows: 

A  soldier  got  a  shrapnel  wound  in  the  left  supraclavicular 
region,  and  had  a  complete  paralysis  of  the  arm,  which  had 
lasted  more  than  a  month.  Electrical  examination  showed 
marked  reaction  of  degeneration  in  the  muscles  controlled 
by  the  musculo-cutaneous  nerve,  as  well  as  a  diminution  of 
electrical  excitability  in  the  muscles  innervated  by  radial 
branches.  On  the  contrary.  In  the  circumflex  territory,  ulnar 
and  median,  electrical  excitability  was  normal.  There  were 
no  vasomotor  disorders.  The  diagnosis  of  an  association  of 
hysteria  and  organic  disease  was  made.  Babinski  affirmed 
that  electrification  would  effect  a  partial  cure ;  and  In  point  of 
fact,  the  patient,  after  having  submitted  to  the  current  for 
several  minutes,  was  able  to  use  all  the  muscles  whose  faradic 
contractility  was  normal  or  almost  normal.  Thus,  he  could 
raise  his  arm,  flex  the  thumb,  flex  the  fingers,  close  the  hand, 
and  extend  the  hand  and  fingers.  Flexion  of  the  forearm  on 
the  arm  was  still  difficult,  since  there  was,  in  fact,  a  reaction 
of  degeneration  In  the  muscles  of  the  anterior  region  of  the 
arm.  The  fact  that  the  movements  could  be  partially  exe- 
cuted was  dependent  upon  action  of  the  supinator  longus. 


598  THE   DIAGNOSIS    OF   SHELL-SHOCK 


Gunshot  fracture  of  upper  arm;  recovery  with 
motor  power  in  five  weeks :  Six  weeks  later,  Erb's 
palsy  (plus).  Hypothesis :  *'  Reflex  paralysis  "  pre- 
ferred. 


Case  427.     (Oppenheim,  January,  1915.) 

A  reservist,  26,  was  shot  through  the  middle  of  the  left 
upper  arm,  sustaining  an  oblique  fracture  of  the  humerus, 
August  26.  The  external  wounds  healed  In  a  month;  the 
fracture  somewhat  later.  The  left  arm  was  at  first  stiff  and 
motionless,  but  in  five  weeks  it  could  again  be  moved.  Pains 
disappeared  with  return  of  motility. 

About  the  middle  of  November  the  arm  began  to  lose  power 
to  move  again,  especially  the  muscles  of  the  upper  arm. 
November  20,  the  patient  showed  atrophic  paralysis  (left 
deltoid,  biceps,  brachialis  internus,  and  supinator  longus) 
suggesting  at  first  glance  the  appearance  of  an  Erb's  palsy; 
but  the  triceps  and  the  adductor  of  the  upper  arm  were  also 
unable  to  move  and  there  was  a  slight  paresis  in  the  distal 
muscles  of  the  extremity.  There  were  no  pains  or  other  ob- 
jective disorders. 

The  diagnosis  of  subacute  poliomyelitis  was  considered. 
Electric  excitability,  however,  was  found  to  be  normal,  both 
faradically  and  galvanlcally. 

When  patient  walked,  the  left  arm  swung  helpless  without 
sign  of  innervation  or  any  tonus.  Abduction  of  the  shoulder 
could  also  not  be  performed,  though  a  slight  flexion  of  the 
forearm  shortly  began  to  be  demonstrable.  If  the  patient 
inclined  his  head  to  the  right,  extended  his  hand  at  the  wrist, 
and  flexed  the  fingers  forcibly,  he  could  then  flex  the  forearm 
somewhat,  and  a  slight  tension  of  the  biceps  and  supinator 
longus  developed.  Sometimes  fibrillary  tremors  developed 
in  deltoid  and  biceps. 

Of  course  a  transient  peripheral  palsy  can  be  produced  by 
pressure  of  the  radial  nerve  without  any  change  of  electrical 
excitability,  but  such  a  change  Is  not  associated  with  atrophy. 

Neuritis  and  poliomyelitis  producing  an  Erb's  palsy  without 


THE  DIAGNOSIS   OF   SHELL-SHOCK  599 

any  effect  upon  the  electrical  reactions  is  an  hypothesis  not 
to  be  entertained. 

Accordingly,  the  hypothesis  of  psychogenic  or  hysterical 
palsy  may  be  set  up.  Yet  an  atonic  atrophic  palsy  with  loss 
of  tendon  reflexes  (supinator)  is  inappropriate.  According 
to  Oppenheim,  this  case  falls  into  the  category  of  the  arthro- 
genic  atrophies.  A  simple  muscular  atrophy  may  follow 
disease  of  joints  and  bones.  However,  such  cases  have  rarely 
shown  a  complete  palsy,  as  in  Oppenheim's  case. 

In  short,  we  return  to  the  old  doctrine  of  reflex  paralysis, 
conceiving  that  a  stimulus  passing  from  the  periphery  influ- 
ences the  gray  matter  in  its  trophic  functions. 

How  much  effect  had  the  psyche  upon  this  condition?  The 
patient  had  stuttered  from  childhood  and  had  sustained  a 
fracture  of  the  skull  at  9,  following  which  his  school  work, 
especially  mental  arithmetic,  had  been  poor.  The  lack  of 
psychic  inhibitions  may  play  some  part  in  the  situation,  but 
on  the  whole,  the  reflex  hypothesis  is  preferred  by  Oppen- 
heim, the  nerve  conceived  to  be  dynamically  affected,  the 
muscles  organically. 


600  THE   DIAGNOSIS    OF    SHELL-SHOCK 


Paralysis :    Hysterical?    organic? 


Case  428.     (GouGEROT  and  Charpentier,  May,  1916.) 

A  soldier,  20,  was  wounded  May  15,  1915,  by  a  large  num- 
ber of  shell  fragments,  15  of  which  struck  the  right  leg,  two 
producing  serious  injuries,  —  the  one,  a  penetrating  wound  of 
the  popliteal  space  followed  by  stiffness  of  the  knee,  later  cured 
by  extraction  of  the  fragments;  the  other,  causing  a  deep 
wound  at  the  internal  malleolus.  The  fragment  was  ex- 
tracted June  3,  but  osteomyelitis  persisted  and  a  fistulous 
contraction  was  developed  in  January,  19 16.  There  was  a 
slight  equinism. 

By  contrast  with  these  deep  bony  lesions  of  the  right  leg, 
on  the  left  side  a  fragment  had  struck  the  dorsum  of  the  left 
foot  at  about  its  middle  point,  along  the  extensors  of  the 
fourth  and  fifth  toes.  The  fragment  was  removed  toward  the 
end  of  June,  1915.  The  wound  closed  in  a  fortnight,  leaving  a 
loose  20  mm.  scar.  The  man  complained  of  pains,  which  he 
called  electrical,  in  the  third  and  fourth  toes,  if  one  bore  down 
on  this  scar,  a  symptom  suggesting  that  the  dorsal  nerves  had 
been  injured.  Immediately  after  the  wound  both  legs  had 
been  paralyzed,  according  to  the  soldier.  He  had  been  ablu 
only  to  drag  himself  along  on  his  shoulders.  This  indetermi- 
nate paralysis  lasted  three  days.  It  may  have  been  hystero- 
traumatic,  or  it  may  have  been  a  sort  of  diffuse  inhibition. 
Just  after  the  injury,  the  left  foot  was  in  contracture,  which 
gave  place  a  month  later  to  paralysis.  Only  the  great  toe 
was  still  able  to  move  a  little.  In  December,  191 5,  the 
patient  still  could  extend  and  flex  the  toes  on  the  left  side 
very  badly,  though  he  could  execute  movements  easily  on 
the  right  side.  There  was  no  stiffness  of  joints;  there  were 
no  tendon  reflex  disorders.  There  were  no  trophic  vasoijiotor 
or  secretory  disturbances. 

The  diagnosis  of  hysterical  paresis  seemed  warranted,  but 
electrical  examination  showed  that  the  troubles  were  organic. 
There  was  an  increase  in  the  faradic  and  galvanic  excitability 
of  the   external   popliteal   nerve.     The  response   was   more 


THE  DIAGNOSIS   OF   SHELL-SHOCK  6oi 

sudden  than  normal,  and  there  was  an  increase  in  faradic  and 
galvanic  excitability  in  the  tibialis  anticus.  There  was  a 
decrease  of  faradic  and  galvanic  excitability  in  the  extensor 
communis  of  the  toes  and  in  the  external  peroneus. 

Thus,  this  patient  after  being  wounded  in  both  feet  May 
15)  191 5>  paralyzed  in  both  feet  for  a  period  of  three  days, 
undergoing  a  contracture  of  the  left  foot  for  a  month,  giving 
place  to  paralysis  of  foot  and  toes,  with  slow  improvement 
from  the  end  of  July,  191 5,  was  still  in  this  latter  state  in 
March,  1916;  though  without  trophic  disorder,  he  showed 
faradic  and  galvanic  over-excitability  of  the  external  pop- 
liteal nerve  and  of  the  tibialis  anticus,  pari  passu  with  dim- 
inished electrical  excitability  for  other  muscles. 


602  THE   DIAGNOSIS    OF    SHELL-SHOCK 


Paralysis :    Hysterical?     organic? 


Case  429.  (GouGEROT  and  Charpentier,  May,  1916.) 
A  man  was  wounded  Oct.  11,  19 14,  on  the  back  of  the 
right  hand.  Two  hours  later,  he  was  attended  at  the  relief 
post.  At  this  time,  his  hand  was  straight,  with  fingers  ex- 
tended. He  said  that  he  could  not  move  his  fingers,  although 
there  was  no  pain  in  them.  Three  hours  after  the  wound, 
the  hands  swelled  and  the  edema  spread  as  far  as  the  middle 
of  the  forearm.  There  was  a  long  suppuration,  complicated 
by  lymphangitis.  All  of  the  fragments  were  removed  October 
26,  1 9 14;  healing  was  complete  in  three  months.  The 
swelling,  however,  persisted  to  June,  191 5,  and  when  the 
swelling  disappeared,  the  hand  began  to  show  drop-wrist. 
The  wound  was  sutured  between  the  second  and  third  meta- 
carpals, and  the  X-ray  showed  that  the  bones  had  not  been 
injured,  nor  had  the  nerves  of  the  forearm  muscles  been 
touched.  The  situation  was  such  that  the  case  was  cata- 
logued "  functional  paralysis." 

October  5,  19 15,  the  hand  was  still  drooping,  fingers  ex- 
tended, and  middle  finger  and  ring  finger  trembling.  A 
slight  stiffness  of  wrist  and  fingers  did  not  interfere  with 
movements.  Extension  of  the  wrist  could  be  made  very 
slightly  above  horizontal.  Flexion  was  not  quite  complete, 
nor  were  adduction  or  abduction.  Extension  of  the  fingers 
could  be  performed  normally,  as  well  as  that  of  the  thumb, 
but  flexion  was  not  quite  complete.  There  was  a  slight 
palmar  retraction.  Such  were  the  movements  that  could  be 
produced  electrically.  Voluntarily,  flexion  of  the  wrist  was 
good,  abduction  and  adduction  incomplete;  extension  could 
not  be  executed  to  the  horizontal  position.  There  was  a 
tendency  to  flexion  of  the  ring  finger.  When  the  patient  tried 
to  flex  the  middle  and  index  fingers,  these  fingers  trembled  but 
did  not  flex.  Weak  extension  and  abduction  of  the  thumb 
but  without  opposition  could  be  voluntarily  performed; 
adduction  good;  flexion  of  the  first  phalanx,  weak;  of  second 
phalanx,  better.     Slight   muscular  atrophy  of  the  forearm, 


THE   DIAGNOSIS   OF   SHELL-SHOCK  603 

which  was  one  centimeter  less  in  circumference  than  the  left. 
The  hand  was  subject  to  a  general  atrophy;  the  skin  reddish 
and  moist.  The  X-ray  showed  a  decalcification  of  all  the 
bones  of  the  hand  and  wrist ;  trophic  disturbance  of  the  small 
carpal  bones  although  the  trauma  had  affected  only  the 
second  interosseous  space.  No  joint  lesions  or  periosteal 
thicknesses  were  found  by  X-ray.  There  was  a  slight  hypes- 
thesia  of  the  palmar  surface  of  the  middle  finger  and  of  the 
index  finger.  The  patient  complained  of  sharp  transient  pains 
in  hand  and  fingers. 

In  this  case,  therefore,  a  wound  of  the  back  of  the  hand 
produced  an  immediate  inhibition  of  muscular  action  in  the 
forearm,  a  rapid  edema  of  the  hand  and  arm,  lasting  for 
eight  months  and  followed  by  reflex  disorders. 

There  was  a  considerable  diminution  in  faradic  excitability 
of  the  flexor  brevis  of  the  thumb,  the  anterior  cubital,  the 
flexor  brevis  minimi  digiti,  and  of  the  dorsal  interossei,  and 
slighter  evidence  of  diminution  of  galvanic  excitability  in 
some  of  the  muscles. 

Sollier  is  said  to  have  been  the  first  to  remark  trophic 
bone  disorders  in  cases  of  neuropathic  contracture. 

Re  bone  changes,  Babinski  enumerates  trophic  changes 
in  the  tissue  of  bones  and  joints  amongst  objective  signs  that 
permit  us  to  distinguish  the  reflex  or  physiopathic  disorders 
from  the  hysterical  or  pithiatic  disorders.  Objective  signs 
of  this  group  (indicators  of  reflex  or  physiopathic  disorders) 
are:  (o)  Well-marked  and  persistent  vasomotor  and  thermic 
disorder;  {h)  alterations  of  muscular  tone  (either  hypo- 
tonus,  hypertonus,  or  a  combination  of  the  two) ;  (c)  in- 
crease in  the  mechanical  excitability  of  the  muscles  and 
sometimes  nerves;  {d)  quantitative  changes  in  the  electrical 
excitability  of  the  muscles,  but  without  R.  D. ;  {e)  muscular 
atrophy  and  atrophy  of  skin,  bones,  and  joints.  For  cases 
of  this  nature,  see  especially  Cases  431  and  432  of  Delherm. 


604  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Paralysis :  Hysterical?     organic? 


Case  430.     (GouGEROT  and  Charpentier,  May,  1916.) 
A  man,  22,  was  wounded  September  17,   1914,  in  the  left 
hand,  the  bullet  passing  from  the  lower  part  of  the  fourth 
interosseous  space  out  through  the  palmar  face.     The  bones 
were  not  injured,  and  it  was  evident  that  only  a  few  nerve 
filaments  could  have  been  injured;    but  he  had  a  paralysis 
extending  far  beyond  this  region,   which  increased  little  by 
little  from  November,  1914,  to  August,  191 5.     Babinski,  ex- 
amining him  in  November,  1914,  had  made  the  diagnosis  of 
psychic  paresis  of  the  extensors  with  diminution  of  electric 
excitability,  with  a  very  slight  slowing  of  the  contraction  of 
the  last  two  interossei  and  the  hypothenar  eminence,  con- 
nected with  lesion  of  the  branches  of  the  ulnar  nerv^e.     The 
disorder  spread  to  the  flexors  of  the  fingers  and  the  thumb 
muscles.     The  fifth  finger  was  flexed  at  rest;  there  was  no 
stiffness  of  joint  or  tendon  retraction.     The  extensors  and 
flexors  of  all  the  fingers  and  the  thumb,  and  the  abductor  of 
the  thumb  showed  paresis.     The  thumb  was  able  to  oppose; 
the   hands    were    cyanotic.     Augmentation    of    these    phe- 
nomena In  a  period  of  months,  their  bizarre  distribution,  and 
the  preservation  of  the  opposing  power  of  the  thumb  sug- 
gested a  hystero-organic  disease,  and  Bablnskl's  notes  read, 
"  Partial  and  Incomplete  paralysis  of  the  ulnar  nerve,   at- 
tacking slightly  the  hypothenar  eminence  and  the  last  two 
interossei;    psychic  paresis  of  the  extensors  and  flexors  of 
the  fingers  and  thumb  and  of  the  abductors  of  the  thumb." 
Electrical  examination  showed,  however,  that  there  was  not 
only   electrical    disorder    of   the    common    extensors   of   the 
fingers,  the  extensor  proprlus  of  the  index  and  of  the  ring 
fingers,  of  the  long  and  short  extensors  of  the  thumb,  but  also 
there  was  a  considerable  diminution  to  faradic  and  galvanic 
reaction  in  extensor  ossis  metacarpi  polllcis,  the  radlals,  the 
supinator  longus,  the  pronator  teres,  the  large  and  small  pal- 
mar, the  common  and  superficial  flexors  of  the  fingers,  the 
muscles  of  the  thenar  eminence,  the  anterior  ulnar,  and  the 


THE   DIAGNOSIS   OF    SHELL-SHOCK  605 

anterior  biceps  and  brachial.  In  short,  there  was  an  irradia- 
tion of  seemingly  organic  phenomena  in  the  domain  of  the 
radial,  median,  and  the  non-injured  part  of  the  cubital 
distribution,  as  well  as  in  the  distribution  of  the  musculo- 
cutaneous. Apparently,  organic  paralytic  disorder  had  spread 
even  to  the  biceps  and  had  increased  over  a  period  of  many 
months  after  the  wound  had  healed. 

Re  what  he  terms  organo-hysterical  association,  Babinski 
proposes  to  distinguish  it  from  hystero-organic  association. 
In  Babinski's  organo-hysterical  association,  the  organic  symp- 
toms are  preceded  by  hysterical  symptoms.  These  cases 
of  organo-hysterical  association,  —  e.g.,  a  case  in  which  a 
hysterical  monoplegia  is  followed  by  a  musculospiral  crutch 
paralysis,  —  are  one  of  the  mainstays  of  the  proof  that 
hysteria  and  simulation  cannot  be  confounded.  Babinski 
concedes  that  he  has  sometimes  said  that  hysteria  was  a 
sort  of  semi-simulation;  yet  a  semi-simulation  is  not  a  simu- 
lation. 

As  for  Babinski's  hystero-organic  association,  we  here  deal 
with  cases  of  organic  paralysis  or  contracture  in  which  the 
fundamental  disorder  is  organic,  and  the  psychic  disorder  is 
grafted  upon  it.  Both  the  fundamentally  organic  and  the 
fundamentally  hysterical  associations  are  instances,  accord- 
ing to  Babinski's  phrase,  of  symptomatic  Incompatibilities. 
In  such  instances,  the  hysterical  part  of  the  disorder,  whether 
grafted  or  original,  is  dissolved  by  psychotherapy.  There  is 
a  third  group  of  symptomatic  Incompatibilities,  namely, 
the  hystero-reiiex  associations,  In  which,  e.g.,  a  hysterical  gait 
is  combined  with  vasomotor  and  thermal  disturbances. 
There  may  even  be  combinations  of  all  three  types  of  disease, 
namely,  the  type  of  structural  disease,  of  vasomotor  disorder, 
and  of  hysteria,  in  what  would  then  be  termed  a  hystero- 
reflex- organic  association. 


6o6  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Wound  of  toes  —  Wound  of  arm :  Reflex  or  physio- 
pathic  paralyses,  diagnosis  and  treatment. 


Cases  431  and  432.  (Delherm,  September,  1916.) 
A  soldier  was  wounded  in  the  soft  parts  of  the  last  two 
toes  and  in  the  furrow  between  toes  on  the  left  side,  Septem- 
ber 15,  1 9 14,  arriving  in  the  Central  Physiotherapeutic  Ser- 
vice of  the  17th  Army  Region,  December  27,  1915,  left  foot  in 
varus,  with  marked  contracture  of  tibialis  anticus,  though 
passive  movements  of  flexion,  extension,  adduction  and  ab- 
duction were  well  performed.  There  was  a  slight  atrophy 
of  the  leg  (33  cm.  left  to  34  cm.  right).  The  scar  was  a 
little  painful,  and  there  was  a  slight  degree  of  hypesthesia  of 
foot  and  lower  leg.  The  foot  was  cold  and  cyanotic ;  the  re- 
flexes were  normal.  An  electric  examination  in  the  region 
of  the  external  popliteal  branch  of  the  sciatic  ner\^e  showed 
that  there  was  no  electrical  disorder  either  faradic  or  voltaic. 
Another  case  was  wounded  in  the  right  arm  by  a  shell 
fragment  September  7,  1914,  and  showed  two  scars  above  the 
epitrochlea  and  along  the  internal  border  of  the  triceps. 
Examination  December  30  showed  a  normal  elbow  move- 
ment, pronation  and  supination,  with  slight  flexion  in  repose 
of  the  palm  of  the  hand  and  the  fingers.  Active  flexion 
movements  of  the  fingers  could  be  performed  only  imper- 
fectly, and  the  finger  pad  could  only  be  brought  within  three 
fingers  breadths  of  the  palm,  despite  the  greatest  effort  on  the 
part  of  the  patient.  Minute  passive  movements  were  en- 
tirely possible.  The  fifth  finger  could  not  be  abducted  and 
both  abduction  and  adduction  of  the  third  and  fourth  finger 
could  not  be  made  on  account  of  the  nerve  lesion.  The 
thumb  was  in  a  condition  of  contracture  which  placed  it  in 
abduction  in  front  of  the  index  finger,  and  the  thumb  could 
not  oppose.  Passive  movements,  on  the  other  hand,  were 
entirely  possible.  The  hand  was  flexed  upon  the  forearm 
through  hypertonia  of  the  flexors,  which  could  be  easily 
overcome  with  slight  but  distinct  resistance.  The  hand  was 
in  the  position  of  a  radial  paralysis.     There  was  a  slight  de- 


THE  DIAGNOSIS   OF   SHELL-SHOCK  607 

gree  of  muscular  atrophy.  Tendon  reflexes  were  normal. 
Electric  examination  showed  that  stimulation  of  the  ulnar 
nerve  at  the  elbow  was  unable  to  produce  flexion  of  the  last 
two  fingers  or  any  movement  in  the  hypothenar  eminence, 
of  which  the  muscles  were  also  not  excitable.  The  interos- 
sei  could,  however,  be  made  to  contract.  The  median  and 
radial  nerves  were  normal  electrically.  The  above  exam- 
inations were  with  the  faradic  current. 

With  the  galvanic  current  the  ulnar  nerve  proved  unex- 
citable  at  the  elbow,  and  the  muscles  of  the  hypothenar 
eminence  contracted  more  slowly.  The  median  and  radial 
nerves  and  their  muscles  were  electrically  normal. 

In  short,  there  was  a  complete  R.  D.  of  the  hypothenar 
and  partial  R.  D.  of  the  interossei  as  a  result  of  the  lesion 
of  the  ulnar  nerve.  There  was  nothing  abnormal  in  the 
other  nerves  or  muscles  of  the  arm.  The  attitude  of  radial 
pseudoparalysis  is  due  to  the  contracture  of  the  muscles  of 
the  thenar  eminence. 

As  to  therapy,  the  general  movements  of  flexion  of  the 
fingers,  thumb  and  hand  yielded  a  marked  improvement, 
but  such  results  cannot  be  expected  in  like  cases  unless  a 
physician  or  experienced  masseur  treats  the  case.  Babin- 
ski  and  Froment  have  tried  thermotherapy  and  diathermy 
in  these  cases,  finding  that  the  paralysis  diminishes  and  be- 
comes partial  if  the  limb  is  warm,  although  it  is  important 
that  it  should  not  become  too  warm.  Sometimes  a  few 
treatments  with  diathermy  will  produce  movements  in  a 
case  of  long  standing  paralysis.  Babinski  and  Froment 
counsel  not  only  diathermy,  but  a  general  motor  reeducation. 
The  idea  of  the  diathermy  is  that  the  deeply  penetrating 
heat  affects  blood  vessels  and  muscles,  bringing  about  a  vaso- 
dilatation or  even  a  direct  addition  of  needed  calories.  In 
like  manner,  galvanism,  light  baths,  or  simple  baths  in  com- 
bination, and  with  diathermy,  especially  with  the  diathermy, 
act  favorably.  Casts  and  apparatus  have  also  proved  with- 
out avail,  as  well  as  faradic  or  galvanic  reeducation. 

The  above  two  cases  show  how  in  one  instance  there  may 
be  no  electrical  change  and  in  another  instance  a  slight  one. 
In  these  cases,  reflex  hypertonic  contracture,  hypotonic  par- 


6o8  THE   DIAGNOSIS   OF   SHELL-SHOCK 

alysis,  vasomotor  disorder,  decalcification  of  the  skeleton 
(X-ray),  mechanical  overexcitability  of  muscles,  unmodified 
tendon  reflexes  (except  elective  exaggeration  of  reflex  under 
anesthesia,  e.g.,  a  persistent  unilateral  patellar  clonus  when 
all  other  reflexes  have  been  abolished),  and  disorders  of  elec- 
trical excitation  are  enumerated  by  Babinski  and  Froment. 
Delherm  sums  up  the  electrical  disorders  as  follows: 
Muscle  faradized: 

(a)  No  change. 

(b)  Subexcitablity. 

(c)  Overexcitability. 

(d)  Diminished  contractility  to  faradism,  associated  with 

increased     contractility     by     galvanism     (Char- 
pentier). 

(e)  Anticipated  fusion  of  shocks  (Babinski  and  Froment). 
(/)      Slow    contraction    and    decontraction    on    faradism 

(Charpentier). 
(g)     Rapid  exhaustion  of  rhythmic  faradic  contraction 
with  metronome. 
Muscle  galvanized: 
(a)     No  change. 
{b)     Subexcitability. 

(c)  Overexcitability. 

(d)  Suddenness  of  galvanic  contraction  with  subexcit- 

ability. 
Re  decalcification  and  osteo-articular  changes,  Babinski 
points  out  that  the  reflex  or  physiopathic  phenomena  run 
historically  back  to  John  Hunter,  Charcot,  and  Vulpian. 
Charcot  and  Vulpian  called  especial  attention  to  the  peculiar 
amyotrophy  and  paralysis  which  occurred  In  joint  disease, 
and  upon  the  lack  of  parallelism  betwixt  the  Intensity  of  the 
joint  disease  and  the  severity  of  the  paralysis  or  atrophy. 
The  atrophy  was  without  R.  D. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  609 


Shell-shock:    Functional     blindness     (monosjnnp- 
tomatic) . 


Case  433.     (Crouzon,  January,  1915.) 

A  shell  burst  above  the  head  of  a  sergeant  in  a  battle  near 
Neuf  chateau,  August  22,  1914.  The  man  was  kneeling  at 
the  time;  felt  a  terrible  shock,  slipped  prone,  lost  conscious- 
ness and  woke  in  the  evening  blind.  Next  day  he  could 
hardly  distinguish  light  from  dark.  Yet  the  light  reflexes 
were  normal;   the  fundus  was  normal. 

This  Crouzon  calls  the  symptomatic  triad  for  functional 
nerve  blindness  of  Dieulafoy.  There  have  been  similar  cases 
following  eclipse  of  the  sun  and  nervous  shock.  The  eclipse 
cases  suggest  that  the  bright  flash  might  have  something  to 
do  with  the  sudden  blindness  (yet  blindness  has  appeared  in 
cases  in  which  the  shell  burst  behind  the  patient). 

The  diagnosis  of  temporary  blindness,  with  a  prognosis  of 
early  recovery,  was  made.  The  neurological  examination 
was  normal. 

For  its  suggestive  effect,  glycerophosphate  injections  and 
progressive  reeducative  measures  were  adopted.  The  patient 
was  shown  that  he  could  see,  first,  the  contour  of  objects, 
then  details  and  colors,  then  large  letters  and  later  small 
letters.  In  a  month  the  blindness  was  almost  well.  Five 
months  afterwards  there  was  still  a  certain  haze  over  the 
field  of  vision  and  a  slight  difficulty  in  distinguishing  certain 
colors. 

Jousset  states  that  aside  from  visual  alterations  as  the 
result  of  cranial  trauma,  and  aside  from  various  transitory 
amblyopias  such  as  scintillating  scotoma,  the  main  varieties 
of  amblyopia  are: 

First,  Congenital  amblyopia. 

Second,  Amblyopia  due  to  cerebral  intoxication. 

Third,  Retrobulbar  neuritis  and  toxic  amblyopia. 

Fourth,  Amblyopia  ex  anopsia. 

Fifth,  Hysterical  amblyopia. 

The  most  frequent  amblyopias  among  the  soldiers  are  ex- 


6lO  THE  DIAGNOSIS   OF   SHELL-SHOCK 

anopsia.  Aside  from  a  few  amblyopias  caused  by  prolonged 
occlusion  of  the  eyelids,  ptosis,  or  blepharospasm,  the  most 
frequent  are  due  to  opacities,  ametropia,  and  strabismus. 
The  hysterical  amblyopias  are,  as  a  rule,  associated  with 
blepharospasm  due  to  intense  photophobia,  and  are  some- 
times associated  with  constant  lacrimation.  Vision  at  a 
distance  is  poor.  The  patient  succeeds  in  reading  but  shows 
an  asthenopia  of  fatigue.  The  cornea  and  the  conjunctiva 
are  anesthetic,  and  sometimes  the  eyelids  also,  — the  so- 
called  anesthesia  en  lunettes.  The  pupils  are  large  but  react 
properly.  The  patient  complains  of  many  species  of  dis- 
order; loss  of  the  sense  of  the  third  proportion,  micropsia, 
megalopsia,  diplopia,  erythropsia,  diplopia  in  two  colors,  in- 
verted image,  hemierythropsia,  rotatory  amblyopia.  There 
is  concentrated  limitation  of  visual  fields,  exaggerated  by 
fatigue  and  by  intense  light ;  reduced  in  dim  light  or  when 
the  patient  is  provided  with  smoked  glasses;  enlarged  upon 
the  instillation  of  atropin  or  with  convex  glasses.  As  a 
rule,  with  unilateral  amblyopia,  the  functional  disorders  start 
in  binocular  vision.  Practically  the  most  important  diag- 
nostic feature  is  the  anesthesia,  since  this  cannot  be  readily 
simulated.  Sometimes  corneal  anesthesia  is  found  in  non- 
hysterical  persons,  who  may  perhaps  be  regarded  as  poten- 
tial hysterics. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  6X1 


Retrobulbar  neuritis  (nitrophenol). 


Case  434.     (SoLLiER  and  Jousset,  April,  1917.) 

A  soldier  of  the  54th  Artillery  entered  hospital  45,  Novem- 
ber 4,  1916.  He  had  had  a  slight  paralysis  of  the  left  bra- 
chial plexus  in  1913,  following  a  shoulder  dislocation,  but  the 
only  relic  of  this  when  the  war  began  was  a  deltoid  paresis. 
He  had  been  working  from  August  13,  191 5,  at  the  factory 
in  Saint-Fons,  and  was  as  yellow  as  the  majority  of  the 
workers  there.     He  had  never  shown  xanthopsia. 

The  first  symptoms  of  his  left  brachial  plexus  neuritis  had 
begun  six  months  before,  after  9  months'  work  in  the  factory, 
and  showed  themselves  in  an  increase  of  the  deltoid  paresis, 
with  pains  in  the  hand  and  forearm,  and  cramps  of  the  hand, 
interfering  with  work,  formication  in  the  right  hand  and  in 
the  feet,  diminution  of  visual  peculiarity  (objects  forgotten 
and  reading  difficult) .  It  was  only  in  November  that  he  got 
perturbed  about  these  difficulties,  which  had  begun  in  May. 
There  was  a  paralysis  of  the  levators  and  rotators  of  the  left 
shoulder,  with  a  slight  atrophy  of  the  deltoid  and  of  the 
supra-  and  infraspinatus  muscles.  The  arm  could  be  ex- 
tended almost  to  the  horizontal  with  difficulty.  There  was 
one  centimeter  atrophy.  The  forearm  and  hand  were  not 
atrophic  but  slightly  weak.  There  was  an  anesthesia  of  the 
shoulder-joint  region,  and  of  the  outer  surface  of  the  arm; 
a  hypesthesia  of  the  posterior  surface  of  the  forearm  and 
dorsal  surface  of  the  hand  and  fingers ;  tendon  and  periosteal 
reflexes  normal.  Sometimes  the  hand  would  contract  firmly 
and  could  be  opened  only  by  the  aid  of  the  other  hand.  The 
ner\'e  trunks  of  the  axilla,  upper  arm,  and  forearm,  were 
painful  on  pressure,  especially  on  the  left  side,  and  the  ulnar 
ner\'e  was  thickened  and  rolled  under  the  finger.  The  knee- 
jerk  and  Achilles  jerk  were  abolished  on  the  right;  plantar 
reflex  diminished ;  right  posterior  tibial  nerve  painful  on  pres- 
sure, and  its  territory  was  hypesthetic.  There  were  cramps 
in  the  feet. 

Gymnastics  and  electrotherapy  and  rest  reduced  these 
phenomena.     The  eye  grounds  were  normal;    there  was  a 


6l2  THE  DIAGNOSIS   OF   SHELL-SHOCK 

paresis  of  accommodation,  and  an  absolute  blindness  to 
green,  with  retraction  of  fields  to  15  degrees  in  the  right  eye, 
and  20  on  the  left.  There  later  developed  a  slight  edematous 
neuritis  of  the  nerve,  corresponding  to  the  evolution  of  a 
chronic  retrobulbar  neuritis  of  toxic  origin. 

It  is  the  chronic  retrobulbar  neuritis  which  is  typical  of 
the  so-called  nitrophenol  neuritis,  developing  in  soldiers  em- 
ployed in  making  explosives.  The  above  case  is  accordingly 
exceptional  in  its  association  of  a  severe  peripheral  neuritis 
with  the  optic  neuritis.  Typically,  after  six  months  to  a 
year  in  the  factory,  the  cramps  and  formication  of  the  legs 
are  felt,  and  the  gradual  diminution  of  vision  with  transient 
blindness,  finally  leading  to  Inability  to  read,  sets  in.  The 
green  blindness,  the  accommodative  paresis,  and  diminution 
of  central  vision,  the  concentric  contraction  of  the  visual 
fields,  are  the  usual  story.  At  first  the  eye  grounds  are 
normal;  there  is  then  an  edematous  neuritis,  and  finally  a 
white  atrophy.  According  to  Sollier,  the  accommodative 
paresis  is  like  that  in  post-diphtheritic  paralysis  —  a  dis- 
ease due  to  cerebral  cortex  intoxication.  In  fact,  the  photo- 
motor  reflex  is  normal,  and  what  we  have  is  an  inversion  of 
the  Argyll- Robertson  sign.  These  symptoms  are  those  of 
retrobulbar  neuritis,  of  nicotino-ethylic  origin,  and  it  may  be 
thought  that  the  melinite  was  simply  acting  by  creating  a 
soil  for  alcoholic  intoxication,  but  none  of  the  patients  ex- 
amined has  been  alcoholic,  nor  has  any  been  permitted  to 
smoke  in  the  factory.  The  injurious  agent  is  probably  a 
body  in  the  nitrophenol  series,  perhaps  dinitrochlorobenzol, 
but  whether  this  substance  is  absorbed  through  the  skin, 
inhaled,  ingested  from  the  hands,  or  by  all  three  routes,  is 
doubtful.  These  workers  are  often  cyanotic  while  at  work 
because  the  nitre  products  produce  vasodilatation.  Possibly 
this  dilatation  of  vessels  has  something-  to  do  with  the  neuri- 
tis. The  workmen  will  not  use  the  spectacles  and  antitoxic 
masks  given  them,  and  even  do  not  use  the  rubber  gloves 
constantly.  In  some  factories  only,  a  liter  of  milk  is  given  as 
counterpoison,  every  day. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  613 


Slight  wound  of  occiput :  Ophthalmoplegia  externa, 
infiuencible,  however,  by  tests  and  replaced  by 
spasmodic  convergence  of  globes  with  myosis ;  hys- 
terical stigmata  and  convulsions. 


Case  435.     (Westphal,  September,  191 5.) 

A  German  volunteer,  20,  was  slightly  wounded  in  the 
occiput  by  revolver-shot  at  Ypres.  Then  followed  head- 
aches, vertigo,  and  complaints  of  pains  in  the  eyes  such  that 
he  could  not  open  them  or  see  sidewlse.  May  5,  1915,  he 
showed  a  picture  of  an  ophthalmoplegia  externa:  complete 
immobility  of  the  two  bulbl,  lively  blepharoclonus,  rapidly 
passing  into  blepharospasm,  photophobia.  The  visual  field 
for  white  was  practically  limited  to  the  fixation  point.  Cen- 
tral scotoma  for  all  colors.     Otherwise  normal. 

On  further  examination,  the  apparently  immobile  bulbl 
were  found  to  pass  Into  convergence  upon  request  to  look  to 
the  right  or  left.  Thereafter,  this  position  of  convergence 
was  assumed  If  any  test  made  by  a  strong  light,  such  as  that 
of  a  pocket  flash,  was  used.  The  pupils  contracted  to  the 
maximum  during  this  assumption  of  the  convergent  position 
of  the  globes,  and  no  further  light  reaction  could  be  observed. 
The  convergence  gradually  passed  off  when  the  light  was 
removed.  The  appearance  of  bilateral  external  ophthal- 
moplegia had  disappeared. 

If  the  patient  was  requested  to  follow  a  finger  moved  to 
one  side,  the  globe  of  that  side  to  which  the  finger  was  being 
moved,  stood  unmoved  in  its  central  position,  but  the  other 
globe  followed  the  eye  and  placed  Itself  In  the  convergent 
position.  The  patient  complained  of  diplopia.  Even  after 
the  closure  of  one  eye  a  double  vision  appeared  (monocular 
diplopia).  There  was  achromatopsia.  The  cornea  failed  to 
react  to  stimulation. 

There  was  an  analgesia  of  the  skin  of  the  whole  body,  with 
a  hypesthesia  for  tactile  stimuli  on  the  left  side.  Smell  and 
taste  absent.  The  convergent  position  of  the  globes  with 
myosis  was  preserved  in  the  midst  of  convulsive  seizures, 


6l4  THE  DIAGNOSIS   OF  SHELL-SHOCK 

which  could  be  produced  by  exciting  the  patient.  When  it 
was  attempted  to  dissolve  the  eye  troubles  by  hypnosis,  con- 
vulsive attacks  occurred.  The  patient  was  pronouncedly 
hysterical. 

The  case  is  beyond  question  hysterical,  —  the  phenomena 
consisting  of  an  ophthalmoplegia  externa,  alternating  with 
spasmodic  contracture  of  the  internal  recti,  associated  with 
myosis  and  loss  of  light  reaction.  The  influencibility  of  this 
situation  during  the  process  of  tests,  to  say  nothing  of  the 
other  stigmata,  clinches  the  diagnosis  —  an  important  one, 
since  the  development  of  an  external  ophthalmoplegia  after 
occipital  trauma  might  possibly  be  regarded  as  an  organic 
disease  due  to  hemorrhage  in  the  region  of  the  eye-muscle 
nuclei. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  6l 


Sandbag  drops  on  head:  Internal  strabismus  and 
diplopia.     Various  diagnoses.     Cure  by  lenses. 


Case  436.     (Harwood,  September,  1916.) 

A  four-pound  wet  sandbag  fell  eight  feet  on  the  head  of  a 
sergeant-major,  28,  lying  in  a  Gallipoli  dug-out,  November 
24,  1 91 5.  The  sergeant-major  was  removed  to  Lemnos  with 
headache  and  giddiness,  and  a  week  later  developed  bilateral 
internal  strabismus  with  double  vision  and  head  noises. 
The  diagnosis  was  "brain  tumor"  or  "syphilitic  meningitis 
of  the  base."  On  the  voyage  home,  the  diagnosis  was  altered 
to  "multiple  neuritis  or  neurasthenia." 

He  was  admitted  to  the  I-Cing  George  Hospital,  January  i, 
1916,  unable  to  move  the  eyes  outwards;  they  moved  rather 
poorly  up  and  down.  There  was  a  slight  lateral  nystagmus. 
The  patient  had  been  unable  to  read  or  stand  since  the  acci- 
dent. The  visual  acuity  of  each  eye  was  less  than  6/60,  but 
with  an  arrangement  of  lenses  he  could  get  6/5  with  either 
eye.  He  had  perfect  binocular  vision  and  could  read  ordi- 
nary type  comfortably.  In  a  week's  time  he  was  able  to 
stand  without  support  and  walk  with  a  stick.  WTienever  he 
took  off  the  glasses,  the  strabismus  and  diplopia  immediately 
returned.  Other  combinations  were  tried  but  failed  to  re- 
lieve symptoms.  The  lenses  given  were  +0.375  c.  \'ert.  and 
L.  +0.25  S.  +0.25  C.  75  do. 


6l6  THE   DIAGNOSIS   OF    SHELL-SHOCK 


Hemianopsia :  organic  or  functional? 


Case  437.     (Steiner,  October,  191 5.) 

A  19-year  old  volunteer,  never  ill  (no  nervous  disease  in 
the  family),  after  a  period  of  training  went  into  the  field, 
October  3,  1914.  November  5,  a  shell  struck  the  trench 
nearby  but  failed  to  explode.  Up  to  that  time  everything 
had  been  quiet.  The  soldier  had  been  looking  out  of  the 
loophole,  surveying  the  terrain.  He  felt  a  great  fear,  got  a 
blow  in  the  neck,  fell  down  unconscious,  remained  uncon- 
scious for  an  unknown  time,  and  later  walked  back  with  his 
comrades.  About  an  hour  later,  this  volunteer,  —  who  was  a 
very  intelligent  young  man,  possessing  much  knowledge  of 
biology,  including  the  nature  of  visual  fields,  —  noticed  a 
black  spot  in  the  field  of  vision,  which  came  and  went,  but 
after  a  few  hours  remained  continually  without  disappear- 
ing. Otherwise,  there  was  no  complaint  except  a  feeling  of 
dizziness  when  stooping. 

Upon  examination  there  could  be  found  no  disorder  of  the 
internal  organs.  Neurologically  there  was  blinking,  vaso- 
motor excitability,  slight  reddening  of  the  face,  and  dermato- 
graphia.  An  expert  in  ophthalmology  confirmed  the  exist- 
ence of  a  homonymous  defect  in  the  fields  of  vision.  This 
defect  could  not  be  influenced  by  suggestion  or  by  any  other 
treatment,  nor  did  any  other  change  whatever  occur  in  the 
condition. 

Steiner  inquires  whether  this  hemianopsia  is  to  be  taken  as 
organic  or  functional.  The  air-pressure  of  the  shell  hissing 
past  might  have  produced  a  concussion,  or  the  falling  uncon- 
scious might  have  produced  a  commotio  cerebri  or  a  slight 
hemorrhage.  The  tic-like  blinking  and  vasomotor  excita- 
bility, however,  suggest  functionality. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  617 


Hysterical  pseudoptosis. 


Case  438.  (Laignel-Lavastine  and  Ballet,  January, 
1916.) 

Laignel-Lavastine  and  Ballet  present  a  case  of  what  they 
term  hysterical  pseudoptosis  in  a  patient  who  showed  no 
signs  of  organic  disease  of  the  nervous  system,  and  moreover 
no  special  mental  disorder.  This  soldier,  30  years  of  age, 
working  in  the  auxiliary  service,  suffered  from  a  trouble- 
some lowering  of  his  left  upper  eyelid.  He  went  to  the  front 
in  February,  191 5.  Aside  from  suffering  a  few  mild  and 
temporary  blindnesses  {ebloiiissements) ,  he  was  entirely  well 
up  to  the  time  of  being  wounded,  March  18,  1915,  by  a 
bullet  in  the  arm,  and  a  bullet  occasioning  a  superficial  and 
slight  wound  2^  centimeters  above  the  middle  of  the  left 
eyebrow.  About  three  years  later,  a  shell  burst  near  him 
and  made  a  large  contusion  about  the  right  eye,  without 
hurting  the  globus.  He  was  then  evacuated  to  Chalons-sur- 
Marne,  and  there  remained  for  48  hours,  totally  blind,  prob- 
ably on  account  of  spasmodic  closure  of  his  eyelids.  He 
then  began  to  be  able  to  use  the  left  eye,  which  remained, 
however,  very  photophobic.  A  fortnight  later,  the  wounds 
were  healed,  but  the  patient  found  himself  unable  to  open 
his  right  eye.  Three  months  later  he  returned  to  his  depot, 
and  left  for  the  front  October  24. 

He  was  reevacuated  November  4,  as  unsuitable  for  ser- 
vice. He  was  then  examined  by  an  ophthalmologist  at 
Chartres,  who  found  a  very  mobile  right  pupil  and  a  slightly 
atrophic  right  papilla;  vision  \;  left  eye  normal;  vision  f; 
total  paralysis  of  right  levator  palpebrae  superioris  without 
contracture  of  orbicularis.  There  was  also  paresis  of  the 
left  upper  lid,  which  ceased  when  the  right  eye  was  closed. 
The  right  half  of  the  face  was  anesthetic,  but  there  was  no 
corneal  anesthesia. 

November  15:  Right  eyebrow  lower  than  left;  if  the  head 
was  moved  backward,  the  right  eyelid  followed  the  move- 
ments, and  in  this  position  there  was  no  ptosis. 


6l8  THE  DIAGNOSIS   OF   SHELL-SHOCK 

November  i6:  Analgesia  in  the  super-  and  sub-orbicular 
region.  November  17:  frontalis  and  orbicularis  functions 
normal. 

At  time  of  examination,  patient  complained  of  not  being 
able  to  open  his  right  eye,  and  that  he  could  only  partly  open 
the  left  eye.  To  catch  a  view  of  his  examiner,  he  had  to 
throw  his  head  back  and  to  the  right.  He  could  not  open 
his  eyelids,  and  in  the  effort  to  do  so,  the  forehead  muscles 
contracted;  and  whereas  the  left  eyebrow  was  properly 
elevated,  the  right  eyebrow  was  only  partially  elevated. 
Associated  movements  could  be  noted  in  the  musculature  of 
the  lower  part  of  the  face.  In  looking  to  the  right,  the  eye- 
lids, especially  the  left,  were  elevated  slightly.  The  patient 
complained  of  photophobia.  From  time  to  time,  he  felt 
completely  blind,  and  at  the  end  of  these  spells  of  blindness, 
he  had  a  severe  headache.  His  head  felt  heavy.  Some- 
times on  looking  to  the  left,  he  saw  objects  double,  although 
this  diplopia  had  grown  less  marked  of  late.  All  the  muscles 
of  both  eyes  appeared  to  work  normally.  Upon  pressure  on 
the  right  globus,  especially  pressure  directed  from  above  and 
behind  on  the  internal  part,  the  patient  would  raise  his  left 
eyelid,  but  the  paresis  reappeared  the  moment  the  pressure 
w^as  released;  a  fact  which  the  patient  himself  noted  while  a 
tampon  was  being  placed  upon  his  eye. 

It  seems  there  had  been  a  wound  at  the  external  angle  of 
the  eye,  some  nine  or  ten  years  before,  as  a  consequence  of 
which  the  eyelid  of  this  side  could  never  be  parted  as  well  as 
before.  The  accident  in  question  had  happened  in  1905, 
and  there  had  been  a  slight  suppuration  of  a  wound  2^  centi- 
meters from  the  external  angle  of  the  palpable  fissure. 

The  patient  then  went  through  a  period  of  reeducation. 
It  seemed  that  when  he  was  trying  to  raise  his  eyelids,  there 
was  a  mental  inhibition  which  could  be  overcome  only  by 
effort.  An  attempt  may  be  made  to  resolve  the  phenomena 
into  three  groups: 

First,  enophthalmia  of  the  right  side  (post- traumatic,  ante- 
bellum, a  predisposing  cause). 

Secondly,  a  situation  corresponding  to  so-called  hysterical 
pseudoptosis  of  Charcot  and  Parinaud  (eyelid  falling  with- 


THE  DIAGNOSIS   OF  SHELL-SHOCK  619 

out  wrinkles,  head  thrown  back,  frontalis  contraction  on 
effort  to  open  eyes,  eyelid  lowered) .  The  diagnosis  of  hysteria 
was  supported  by  the  transient  opening  of  both  eyelids  when 
a  sudden  sharp  order  was  given  to  move  the  eye-balls,  and 
further  supported  by  synergic  automatic  lid-movements  when 
the  patient  voluntarily  raised  his  eyes.  He  could  not  raise 
his  eyelids  to  order. 

Thirdly,  functional  ocular  palpable  synergy  (left  eye  open- 
ing upon  compressing  the  right  eye). 


620  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Shell-shock  Rombergism. 


Case  439.     (Beck,  June,  1915-) 

A  soldier,  24,  had  sundry  signs  of  traumatic  neurosis.  A 
curious  and  unexplained  feature  is  the  fact  that  in  the  course 
of  testing  for  Rombergism  he  would  fall  forward  like  a  log  if 
his  head  were  held  in  the  vertical  position,  but  if  it  were 
turned  to  the  right  he  fell  to  the  right;  if  it  were  turned  to 
the  left,  he  fell  backward.  Tests  showed  that  he  had  no 
disease  of  the  vestibular  apparatus  and  no  sign  either  of 
cerebral  or  of  cerebellar  disease. 

The  question  is  raised  whether  shell-shock  can  produce  a 
differential  Rombergism  such  as  hitherto  would  have  been 
explained  on  the  basis  of  some  organic  vestibular  disease. 

Re  Rombergism,  see  especially  Bourgeois  and  Sourdille's 
(edited  by  Dundas  Grant)  remarks  on  disturbances  of  balance 
which,  if  of  labyrinthine  origin,  obey  Romberg's  law,  namely, 
are  greatly  increased  with  the  eyes  closed.  Upon  test,  how- 
ever, normal  equilibrium,  tottering,  or  a  tendency  to  fall  will 
be  usually  found.  The  tendency  to  fall  is,  as  a  rule,  toward 
the  side  of  the  affected  labyrinth,  yet  it  varies  according  to 
the  position  of  the  head;  that  is  to  say,  actually  upon  the 
position  of  the  labyrinth  with  relation  to  the  body.  If  there 
is  a  lesion  of  the  right  labyrinth,  for  example,  and  the  head 
is  turned  to  the  right,  falling  is  to  the  right;  but  if  the  head 
is  turned  90  degrees  toward  the  right,  the  patient  tends  to 
fall  backward  because  in  fact  the  injured  right  labyrinth  has 
now  become  posterior  in  position.  But  if  the  head  with  the 
injured  right  labyrinth  is  displaced  90  degrees  to  the  left,  the 
tendency  would  be  to  fall  forwards. 

According  to  Beck,  there  was  in  his  case  of  Shell-shock 
Rombergism  no  ear  disease  or  any  evidence  of  cerebellar  or 
cerebral  disease. 

Walking  with  the  eyes  open  yields  in  marked  instances  a 
sidewise  bending  or  even  the  classical  staggering  called  the 
duck's  walk  and  drunken  gait  upon  a  broad  base.  The 
most  delicate  test,  according  to  Bourgeois  and  Sourdille,  is 


THE   DIAGNOSIS    OF   SHELL-SHOCK  621 

the  Babinski-Weil  test  of  walking  with  the  eyes  shut.  A 
man  with  labyrinthine  disease  deviates  from  the  straight 
path  (he  is  made  to  walk  forwards  and  backwards  ten  times 
in  a  clear  space) ;  bends  pretty  constantly  to  one  side  when 
walking  forward,  and  pretty  constantly  to  the  other  side 
when  walking  backwards.  Spontaneous  and  Babinski's  in- 
duced nystagmus  (rotation;  caloric)  and  Babinski's  voltaic 
vertigo  test  are  the  other  tests  commonly  employed  in 
equilibrium  investigation. 


622  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Otology  and  neuropsychiatry  should  go  hand  in 
hand. 


Case  440.     (RoussY  and  Boisseau,  May,  191 7.) 

A  soldier  in  the  engineers,  29,  entered  the  neuropsychiatric 
center  at  Scey-sur-Saone,  August  23,  1916.  His  diagnosis 
was:  organic  shock  syndrome  with  right-side  deafness  and 
tremors.  He  carried  a  ticket  showing  an  otological  exam- 
ination :  tympanum  normal ;  Rombergism  absent ;  walks  with 
eyes  closed  swerving  to  right ;  tends  to  fall,  eyes  closed,  on 
standing  on  one  foot;  vertigo  produced  by  rotation  in  either 
direction ;  no  nystagmus  either  spontaneous  or  by  test ;  deaf- 
ness especially  on  the  right  side;  equilibrium  function  in- 
sufficient. 

The  patient  had  undergone  shock  in  April,  191 5,  being 
buried  and  then  losing  consciousness  for  twenty- four  hours. 
The  tremors  appeared  next  day,  and  also  deafness  but  with- 
out speech  disorder.  Nine  comrades  are  said  to  have  been 
killed  beside  him.  The  hospital  ticket,  April  13,  said:  deaf- 
ness and  multiple  contusions  from  shell  explosion.  The 
patient  was  evacuated  to  Clarmont-Ferrand  and  went  back 
to  service  with  the  same  tremor  and  auditory  disorder.  He 
was  shortly  sent  back  to  the  interior  for  six  months  and  re- 
turned improved  to  the  front  August,  1915.  But  he  heard 
the  cannon  in  the  distance,  and,  under  the  influence  of 
emotion  and  the  fatigue  of  the  journey,  the  tremors  and 
deafness  reappeared. 

The  tremor  was  generalized,  involving  both  arms  and  legs 
and  a  slight  lateral  movement  of  negation  of  the  head  every 
ten  or  twelve  seconds.  Occasionally  tonic  contracture  of  the 
face,  lips,  cheeks,  forehead;  tremors  of  tongue;  winking. 
The  tremors  were  somewhat  suggestive  of  toxic  tremors. 

The  deafness  was  evidently  exaggerated.  Voltaic  vertigo 
tested  normal.     Reflexes  normal. 

The  diagnosis  psychoneurosis  was  made  and  the  patient 
was  rigorously  isolated,  given  a  long  psychotherapeutic  talk 
concerning  the  nonreality  of  his  deafness  and  his  vertigo  and 


THE  DIAGNOSIS   OF   SHELL-SHOCK  623 

the  possibility  of  cure  by  means  of  a  very  disagreeable  elec- 
trical treatment.  He  made  improvement  upon  psycho- 
electrical  treatment  and  the  next  day  both  tremors  and  deaf- 
ness had  greatly  diminished.  September  4,  the  patient  was 
considered  completely  well.  There  was  a  slight  diminution 
of  hearing  in  the  right  ear,  the  whispered  voice  was  heard  at 
50  centimeters  on  the  right  side,  the  watch  at  25  centimeters 
on  the  right  and  60  on  the  left. 

October  5  the  patient  was  sent  back  to  his  corps.  On  the 
evening  of  his  departure,  angry  at  not  having  received  leave, 
he  boasted  to  his  comrades  of  having  passed  but  three  days 
at  the  front  since  his  injury. 

It  is  remarkable,  according  to  Roussy  and  Boisseau  that 
this  patient  had  passed  sixteen  months  without  ever  having 
been  taken  for  a  neuropath  or  treated  as  one.  The  otolo- 
gists gave  the  diagnosis  of  labyrinthine  shock,  but  did  not 
attend  to  the  tremors.  The  pseudo-symptoms  disappeared 
in  six  days  at  the  neurological  center  and  the  cure  had  lasted 
six  weeks  at  the  time  of  report. 

Re  otology  in  these  cases,  see  Bourgeois  and  Sourdille's 
book  mentioned  under  Case  No.  439,  particularly  Chapter 
III,  upon  the  functional  examination  of  hearing.  In  the 
present  instance,  it  will  be  noted  that  voltaic  vertigo  tested 
out  normal.  According  to  Bourgeois  and  Sourdille,  the 
Babinski  electrical  test  is  the  most  convenient  one  to  begin 
with,  to  learn  in  a  few  moments  whether  the  vestibular 
system  is  working  normally  or  not.  These  authors  found 
amongst  twelve  patients,  three  normal  reactions  and  one 
instance  of  hypo-excitability  amongst  four  subjects  who,  by 
other  tests,  failed  to  show  vestibular  disturbance.  Inexcita- 
bility  as  to  voltaic  vertigo  was  found  in  one  man  with  a 
destroyed  labyrinth.  There  were  four  instances  of  hyperex- 
citability  in  Babinski's  cases  with  marked  equilibrium  dis- 
order. A  case  of  Meniere's  disease  yielded  the  same  results. 
According  to  the  intensity  of  the  current,  the  following  phe- 
nomena (in  addition  to  the  pricking  sensation)  are  noted; 
{a)  salty  taste;  {b)  sidewise  swaying  with  slight  vertigo; 
(c)  nystagmus  with  more  pronounced  vertigo;  {d)  sensa- 
tions of  sound.     In  short,  nerve  branches  that  go  through 


624  THE    DIAGNOSIS   OF    SHELL-SHOCK 

the  petrous  bone,  namely,  the  chorda  tympani,  the  vesti- 
bular nerve,  and  the  cochlear  nerve,  have  been  successively 
stimulated.  Babinski's  test  was  published  before  the  Barany 
work  on  induced  nystagmus,  but  Barany's  rotation  test  for 
the  physiological  excitation  of  the  semi-circular  canals,  and 
his  caloric  test  for  the  investigation  of  the  ears  and  canals 
separately  are  to  be  utilized  in  addition  to  the  Babinski 
voltaic  test.  Babinski's  law  of  voltaic  vertigo  is  that  a  nor- 
mal subject  inclines  to  the  side  of  the  positive  pole ;  a  patho- 
logic subject  falls  to  the  side  to  which  he  tends  to  incline 
spontaneously.  If  the  labyrinth  has  been  destroyed,  there 
has  been  no  reaction. 

Re  Case  440,  Roussy  and  Boisseau  in  their  capacity  as 
neuropsychiatrists,  point  out  the  inadequacy  of  an  otological 
examination  taken  by  itself.  They  insist  that  neuropsychi- 
atrists should  be  called  in.  It  is  probably  equally  true  that 
neuropsychiatric  work  upon  deaf  cases  is  often  inadequate 
on  account  of  the  lack  of  otological  examinations.  Accord- 
ing to  Bourgeois  and  Sourdille,  the  expert  otologist's  prob- 
lems are  as  follows:  (a)  Deafmutism;  here  Gault's  cochleo- 
palpebral  reflex  is  of  value.  The  hearing  of  a  sudden  noise 
causes  contraction  of  the  orbicularis  palpebrarum  on  the 
side  upon  which  the  noise  is  suddenly  and  unexpectedly 
made.     Eyelash  tips  are  particularly  watched. 

{h)  Complete  bilateral  deafness.  This  is  practically  never 
organic;  complete  bilateral  deafness  is  a  phenomenon  either 
of  traumatic  hysteria  or  of  simulation.  Sundry  methods  of 
surprising  the  patient  into  hearing  have  been  adopted.  The 
practice  of  teaching  lip-reading  to  simulators  and  hysterics 
has  led  to  some  difficulties  in  diagnosis,  but  tests  have  been 
produced  by  Cosset  (of  one  sound  with  the  lips  set  to  form 
another,  and  the  like)  which  are  of  service. 

(c)  Extreme  bilateral  dulness  of  hearing. 

{d)  Total  unilateral  deafness.  For  the  minutiae  of  tests 
for  these  types  of  hearing  disorder  and  their  simulation  and 
exaggeration,  see  the  War  Manual  of  Bourgeois  and  Sour- 
dille. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  62' 


Jacksonian  syndrome :  Hysterical. 


Case  441.  (Jeanselme  and  Huet,  July,  1915.) 
A  Lieutenant  of  Infantry,  32,  was  struck  by  a  bullet  Sep- 
tember 6,  19 14,  in  the  upper  part  of  the  left  temporal  fossa 
4  cm.  above  the  external  auditory  meatus.  He  did  not  lose 
consciousness,  but  had  the  sensation  as  if  his  head  had  been 
shot  off,  and  about  three  minutes  later  he  turned  about, 
fell  down,  and  lost  consciousness.  However,  he  regained 
consciousness  a  few  minutes  later  and  walked  with  support 
for  about  an  hour.  At  the  ambulance,  he  lost  consciousness 
again,  for  half  an  hour.  He  was  then  carried  to  Amalie-les- 
Bains.  The  trip  lasted  108  hours.  The  left  side  of  the  face 
was  now  swollen  so  that  he  could  not  open  the  eye  nor 
could  he  chew  from  swollen  mucosa  folded  between  the  jaws. 
The  bullet  was  removed  Sept.  12,  from  just  below  the  scalp 
outside  the  bone,  the  point  being  slightly  bent  back.  The 
bone  had  been  depressed  slightly  for  an  area  the  size  of  a 
franc  piece,  and  pressure  at  this  point  yielded  a  feeling  of 
pain  and  discomfort.  There  was  no  suppuration.  After  a 
week,  the  man  got  up.  He  returned  to  his  depot  October  3 
or  4  and  was  about  to  rejoin  his  corps  when  he  had  a  sensation 
of  pressure  in  the  head  and  fell.  \A'hen  he  came  to  himself 
he  found  that  there  was  a  frothy  saliva  at  the  left  side  of  the 
mouth  and  that  the  whole  left  side  of  the  body  felt  weak. 
The  tongue  had  not  been  bitten  nor  had  urine  been  passed, 
and  twenty  minutes  later  he  felt  as  well  as  ever.  He  re- 
turned to  the  front  in  the  Argonne,  ha\dng  from  time  to 
time  similar  crises,  —  at  least  once  a  week.  Ordered  to  take 
a  trench  the  night  of  January  17,  he  failed  the  first  time, 
about  midnight,  but  succeeded  at  four  in  the  morning,  —  just 
afterward  falling  exhausted  in  another  crisis,  with  uncon- 
sciousness. The  stretcher  bearers  took  him  back  and  he  was 
evacuated  to  Perpignan.     He  had  two  con\nilsions. 

While  with  his  family  the  crises  grew  in  number  to  three 
or  four  a  week,  and  sometimes  twice  a  day.  Upon  request, 
he  was  sent  to  hospital  in  the  Pantheon  May  5. 


626  THE  DIAGNOSIS    OF   SHELL-SHOCK 

There  was  always  a  sensory  aura,  consisting  in  a  violent 
shock  felt  in  the  left  side  of  the  cranium  like  a  blow  of  a  club. 
There  immediately  followed  a  crawling  sensation  in  the  fin- 
gers and  hand  of  the  left  side,  running  up  the  arm,  with  loss 
of  consciousness  coming  on  before  the  crawling  reached  the 
elbow.  The  seizure  would  last  two  or  three  minutes.  There 
was  no  initial  cry.  The  face  grew  pale.  There  was  apnea, 
and  frothy  fluid  running  out  of  the  left  side  of  the  mouth. 
There  was  no  jerking  of  face  or  limbs;  at  the  end  of  the 
seizure  there  were  no  deep  inspirations.  The  extremities  of 
the  left  side  were  rather  flaccid  during  the  attack. 

A  hemianesthesia  was  found  affecting  both  skin  and 
mucosae  of  the  left  side,  and  a  slight  retraction  of  the  visual 
field  on  the  left  side  was  found.  There  were  no  other  sen- 
sory disorders;  the  knee-jerks  were  lively  on  both  sides  but 
not  actually  exaggerated.  Plantar  stimulation  was  not  per- 
ceived on  the  left  side.  The  toes,  except  the  great  toe,  were 
slightly  extended.  The  fascia  lata  reflex  failed  to  demonstrate 
itself.  On  the  right  side  the  great  toe  went  into  flexion 
on  forcibly  stimulating  the  sole.  Sometimes  the  abdominal 
reflex  on  the  left  side  was  weak  or  even  absent.  The 
patient,  who  had  never  been  nervous,  had  now  become  so 
since  his  attacks.  He  had  had  nocturia  up  to  12.  There 
was  no  evidence  of  neurosis  or  psychosis  in  the  family. 
Bromides  diminished  the  crises  a  little  in  number.  Static 
electricity  was  given  from  January  8,  —  no  attacks  for  8  to 
10  days. 

According  to  Jeanselme  and  Huet,  this  is  a  case  of  Jack- 
sonian  syndrome  of  an  hysterical  nature,  about  which  it 
may  be  noted  that  the  bullet  struck  the  left  side  of  the  skull 
and  the  hemianesthesia  and  muscular  resolution  appeared  on 
the  same  side  as  the  injury. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  627 


Leg  tic :  Phobia  against  crabs. 


Case  442.     (DuPRAT,  October,  1917.) 

A  man,  shell-shocked  in  1916  (with  loss  of  consciousness, 
disorientation  and  confusion  followed  by  nightmares,  mem- 
ory disorder,  attention  disorder,  irritability,  mental  insta- 
bility and  over-emotionalism)  later  still  showed  a  choreiform 
tic.  He  had  a  knife-grinding  movement  of  the  left  leg  which 
made  standing  and  walking  difficult.  There  were  no  signs 
in  the  reflexes  or  reactions  of  organic  disease.  The  man  him- 
self said  that  he  felt  a  sensation  like  little  electric  shocks  when 
his  foot  touched  the  ground,  a  sensation  like  pinching.  He 
also  had  certain  hysteriform  crises.  He  was  able  to  remem- 
ber nightmares  in  which  he  felt  as  if  he  had  fallen  into  a  hole 
where  there  were  crabs.  In  point  of  fact,  he  had  a  true 
phobia  against  crabs,  crayfish,  lobsters  and  the  like;  if  he 
saw  one,  he  always  felt  as  if  he  were  going  to  have  a  new 
crisis.  The  defense  movement  of  the  leg  and  foot  was 
against  a  supposed  pinch  of  the  crab.  At  rest,  there  was  no 
trace  of  the  choreiform  movement.  The  tic  was  especially 
marked  when  the  man  was  suddenly  asked  to  get  up  and 
walk.  In  a  few  days,  when  he  had  become  more  clearly 
conscious  of  his  phobia  and  had  slept  better,  the  tic  grew 
appreciably  less. 


628  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Convulsions  reminiscent  of  fright. 


Case  443.     (DuPRAT,  October,  191 7.) 

A  soldier,  28,  was  blown  up  February  8,  191 5,  by  a  shell 
burst.  He  sustained  no  contusions  but  became  completely 
mute.  On  July  3,  he  began  to  speak  in  a  low  voice.  The 
torpillage  treatment  was  unsuccessful  because  the  man  felt 
a  morbid  apprehension  that  the  vibration  of  a  loud  voice  or 
even  of  a  rapid  walk  would  resound  In  his  brain.  He  had  a 
sort  of  noise  phobia,  probably  maintained  by  nightmares 
M'hlch  frequently  woke  him  up  with  a  jerk  though  he  could 
not  remember  their  content.  On  the  way  back  to  his  depot 
this  man  got  off  the  train  at  the  first  station  and  went  to  a 
hospital  complaining  that  the  vibration  of  the  train  was  going 
to  be  transmitted  to  his  brain.  Hysteriform  crises  developed 
in  a  few  days. 

According  to  Duprat  these  crises  are  nothing  but  a  psycho- 
motor development  of  the  Initial  complex.  The  clonic  and 
tonic  convulsions  are  reminders  of  his  states  of  extreme 
fright,  a  phenomenon  of  revival  of  the  ideo-affectlve  process, 
aggravated  however  by  the  oniric  or  post-oniric  Images. 

Re  diagnosis  of  hysterical  fits,  the  absence  of  facial  cya- 
nosis, sub-conjunctlval  hemorrhages,  petechlae  of  skin,  and 
the  Bablnski  reflex  are  suggestive  for  hysteria.  Bablnski 
points  out  that  the  initial  cry,  the  fall,  the  loss  of  conscious- 
ness, the  tongue-biting,  the  bloody  frothing  at  the  mouth, 
the  urinary  incontinence,  and  the  post-convulslve  prostra- 
tion can  all  be  consciously  or  unconsciously  Imitated.  Hys- 
terical convulsive  movements  are  apt  to  be  of  wide  range, 
gestlculatory,  and  opisthotonlc. 

Bablnski  announces  to  the  supposed  hysteric  that  he  Is 
going  to  reproduce  the  attack,  as  he  is  perfectly  able  to  do 
by  electricity.  A  mild  current  or  mere  electrode  applica- 
tion suggests  a  fit  In  a  hysteric,  often  very  quickly.  Babln- 
ski now  announces  that  he  can  arrest  the  fit;  carries  out 
some  selected  procedure,  and  stops  the  fit.  During  the 
hysterical  fit,  the  patient  of  course  hears  what  Is  being  said 
and  during  this  time  wrong  suggestions  must  not  be  offered. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  629 


Fugue  in  a  motor  cyclist,  with  prodromal  fatigue  and 
subsequent  delusions  —  recovery  in  six  weeks. 


Case  444.     (Mallet,  July,  191 7.) 

A  motor-cyclist,  36,  with  the  colors  from  the  outbreak  of 
the  war,  about  April,  1916,  grew  very  weary,  suffering  from 
headache  and  seizures  without  loss  of  consciousness.  Finally 
there  was  a  voice:  "Sleep,  you  must  sleep."  Then  other 
voices;  then  ideas  of  thought  transference  with  people 
around  him. 

Observed  in  the  psychiatric  center,  May  12,  19 16,  he  had 
the  same  ideas  of  thought  transference,  and  he  made  as  if  to 
talk  with  the  attendants  by  responsive-looking  gestures. 
Sometimes,  he  said,  fluid  struck  his  forehead,  calling  on  his 
thought.  Whereupon  he  listened.  The  man  made  no  com- 
plaints about  his  plight,  was  not  astonished  in  any  wise  at 
what  was  happening,  nor  did  he  seek  to  explain  it.  There 
was  nothing  in  his  history  to  suggest  psychopathy  except 
perhaps  that  his  father  was  unknown. 

The  diagnosis  of  a  chronic  hallucinatory  psychosis  was 
made,  but  the  outcome  promptly  overset  the  diagnosis.  The 
man  talked  with  ward-mates,  and  particularly  with  another 
patient  who  also  talked  about  thought  transference.  This 
shook  the  man  in  his  convictions,  and  he  decided  that  it  was 
but  imagination  and  delirium. 

He  now  told  his  story:  How  it  seemed  that  he  had  in  his 
thoughts  the  phrase,  "Sleep,  you  must  sleep;  "  how  he  had 
gotten  up,  saying,  "No;  "had  noticed  the  others  paying  no 
attention  to  him;  had  gone  back  to  his  work  and  from  that 
moment  had  begun  to  go  into  delirium.  During  this  de- 
lirium or  delusional  state,  his  whole  life  from  birth  up,  came 
back  to  him,  as  If  some  one  were  telling  him.  The  head- 
aches, which  he  at  first  felt  due  to  Hertzian  waves,  suddenly 
ceased. 

Shortly,  however,  a  new  phase  had  set  In,  in  which  he  felt 
himself  surrounded  by  spies  and  that  others  had  control  of 
his  thoughts  and  were  reading  them.     In  fact,  he  grew  a 


630  THE   DIAGNOSIS    OF   SHELL-SHOCK 

little  proud  of  the  fact  that  people  reading  newspapers  all 
around  him  were  actually  reading  his  own  thoughts.  The 
letters  he  wrote  were  being  dictated.  May  9,  he  spent  a 
night  with  a  succession  of  nightmares,  and  woke  up  with  the 
firm  purpose  of  going  back  to  Paris  by  motor  cycle  to  find 
the  spies.  He  described  his  fugue  and  the  thousand  ideas  he 
had  on  the  way,  his  arrest,  his  imprisonment  in  a  cell  of 
Hertzian  waves  with  a  smell  of  sulphur  and  poisoned  bread 
—  a  necessary  fate  on  account  of  the  spies. 

On  arrival  at  hospital,  he  had  not  known  what  was  going 
forward.  The  nurses  were  giving  him  milk  to  destroy  the 
taste  of  sulphur;  the  delirium  then  grew  less  and  less.  The 
room-mates  were  neutrals,  war- weary;  he  seemed  to  be  read- 
mg  the  newspapers  before  his  mates,  and  they  seemed  to  be 
talking  of  thought  transference.  May  20,  the  ward  was 
changed.  The  new  ward- mates  did  not  believe  in  thought 
transference  and  laughed,  causing  the  man  to  doubt. 

June  2,  the  cure  was  in  full  process,  and  the  ward  was 
changed  again;  but  in  the  new  ward  was  a  patient  who  had 
the  same  ideas  of  thought  transference  as  the  patient.  At 
this  time,  the  man's  autocrltlque  saw  through  the  delusion. 
He  talked  with  his  telepathic  comrade  and  pretended  to  en- 
gage in  a  fake  conversation  about  it.  The  delusions  shortly 
disappeared,  having  lasted  about  six  weeks. 


THE   DIAGNOSIS   OF    SHELL-SHOCK  63 1 


Ordinary  gunner's  life ;  a  few  days'  feeling  of  moral 
and  physical  discomfort:  Obsession  leading  to 
fugue. 


Case  445.     (Mallet,  July,  1917.) 

An  artilleryman,  32,  gave  himself  up  a  few  kilometers 
back  of  the  lines,  three  days  after  deserting  his  post.  The 
man  was  a  very  good  gunner  and  had  never  been  punished 
once.  Moreover,  the  battery  was  not  under  any  special 
bombardment,  and  he  had  been  in  the  same  place  a  number 
of  weeks. 

He  explained  that  he  had  gotten  tired  during  the  last  few 
days.  Everything  was  well  at  home  and  in  the  regiment, 
but  he  felt  sad,  his  head  felt  bad,  and  he  couldn't  sleep. 
Something  drew  him  to  leave,  but  then  ^^  sang  froid  came 
back  to  me,  and  I  gave  myself  up."  He  had  lived  the  three 
days  without  eating  and  without  sleeping.  He  was  very 
emotional  over  what  he  had  done,  but  he  began  to  work  and 
asked  that  he  be  sent  back. 

His  mother  had  been  very  nervous.  There  was  a  marked 
facial  asymmetry  and  faulty  arrangement  of  teeth.  The 
man  was  not  alcoholic. 

According  to  Mallet,  in  these  cases  of  fugue,  and  in  other 
cases  of  absolute  delirium  of  apparently  sudden  onset,  there 
is  a  feeling  of  moral  and  physical  discomfort  for  some  days 
before  the  outbreak.  The  outbreak  itself  is  sudden  on  the 
occasion  of  some  idea,  either  an  obsession  or  a  hallucination. 
Of  all  the  prodromal  signs,  headache  is  the  most  striking. 
According  to  Mallet,  such  fugues  are  the  expression  of  a 
mental  imbalance  allied  to  the  onirism  of  Regis. 


632  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Aprosexia  and  bird-like  movements. 


Case  446.     (Chavigxy,  October,  1915.) 

A  soldier  of  the  dragoons,  25,  entered  Chavigny's  service 
May  30,  191 5.  He  acted  like  a  mechanical  figure,  requiring 
guidance.  The  face  was  without  expression  except  for  the 
mobile  eyes,  and  sudden  bird-like  movements  of  the  head, 
continually  attracted  to  new  noises  and  objects.  An  inter- 
locutor was  glanced  at  but  not  responded  to.  If  an  intense 
electrical  shock  was  passed  through  his  abdomen,  for  ex- 
ample, the  man  would  look  for  a  moment  in  that  direction, 
but  only  the  most  fugitive  defence  reaction  would  be  made, 
and  the  stimulus  could  be  repeated  with  the  same  result,  a 
moment  later. 

After  three  days,  this  aprosexia  began  to  clear,  and  in  four 
or  five  days,  answers  to  questions  and  ordinary  associations 
set  in.  ^Memory  reappeared.  It  seems  that  he  had  been  in 
concealment  in  the  loft  of  a  barn,  when  he  saw  his  com- 
manding officer  carried  by,  having  lost  an  arm  and  a  leg. 
He  lost  consciousness  and  fell  three  meters,  through  the  trap- 
door of  the  loft.  There  was  thus  a  combination  of  trauma 
and  emotional  shock.  No  external  lesion  was  produced  in 
the  fall.  His  memory  showed  a  very  sharply  defined  gap  for 
the  period  of  his  aprosexia  with  the  bird-like  movements,  of 
eight  days,  and  his  memory  was  perfectly  good  up  to  the 
time  of  the  fall.  This  is  one  of  five  cases  observed  by  Cha- 
vigny,  who  remarks  that  there  is  something  in  the  attitude 
of  the  young  child  which  recalls  the  aprosexia  of  these  pa- 
tients. (Perhaps  the  phrase  of  James,  "buzzing,  blooming 
confusion"  might  be  used.)  One  must  go  back  to  a  period 
in  the  child's  development  when  he  is  not  yet  able  to  smile 
or  keep  his  glance  fixed  on  a  shining  object.  On  the  whole, 
the  resemblance  is  closer  to  the  attitude  of  certain  caged  birds. 

Re  aprosexia  and  bird-like  movements,  see  discussion  under 
Case  353.     See  also  Case  334. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  633 


Shell-shock ;   unconsciousness  (45  days) :    Mutism 
(mono  symptomatic) . 


Case  447.     (LiEBAULT,  1916.) 

A  soldier,  32,  had  a  large  caliber  shell  burst  one  meter  from 
him  September  26,  191 5,  lost  consciousness  and  remained 
comatose  45  days.  He  then  got  progressively  better  but 
did  not  recover  speech.  He  was  neither  blind  nor  deaf.  He 
was  examined  at  the  neurological  center  at  Nantes  and  there 
Mirallie  called  him  a  case  of  hysterical  mutism,  'finding  no 
paralytic  disorder  of  any  sort  and  finding  the  patient  able 
to  write  his  story,  to  read  and  to  understand  what  he  read, 
but  without  much  power  of  retention.  He  was  placed  in  the 
phonetic  reeducation  service  IMarch  30,  but  made  no  prog- 
ress. In  the  effort  to  speak  the  patient  made  strong  gen- 
eralized contractions,  Including  contractions  of  his  face  and 
winking  of  his  eyes,  contractions  of  the  jaw,  and  movements 
of  the  neck  muscles.  In  fact,  he  seemed  to  be  agitated  by  a 
sort  of  cervico- facial  tic,  and  sometimes,  although  not  al- 
ways, he  succeeded  in  getting  out  a  loud  voice  sound,  in 
which  one  could  imagine  the  syllable  that  he  was  trying  to 
utter. 

In  this  case  the  mutism  was  evidently  secondary  to  motor 
disorder.  It  is  an  example  of  functional  dyskinesia  (Benon). 
As  long  as  this  functional  dyskinesia  remains,  the  patient  will 
not  speak.  The  respiratory  muscles  are  disordered,  since 
the  respiratory  capacity  does  not  go  over  3  liters.  This 
approaches  the  normal,  however,  and  if  the  subject  cannot 
speak  it  is  because  his  diaphragm  is  subject  to  jerky  or 
cramplike  movements  and  because  the  lips  and  tongue  do 
not  execute  the  proper  movements  either  for  sounds,  syl- 
lables or  words.  Such  a  patient  cannot  protrude  the  tongue 
or  even  bring  it  beyond  the  teeth. 


634  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Shell-explosion :  Recurrent  amnesia. 


Case  448.  (Mairet  and  Pieron,  April,  191 7.) 
A  shock  case  of  Mairet  and  Pieron  had  a  disorder  of  mem- 
ory. Association  paths  were  open  one  day  and  closed  the 
next.  Subjected  to  shell-shock,  September  18,  191 5,  he  was 
found  wandering  in  the  woods  a  few  days  later,  having  com- 
pletely lost  his  memory,  even  for  his  name.  In  November  he 
recovered  his  surname  but  not  his  given  name.  On  stimu- 
lation he  was  gotten  to  remember  his  city,  his  father,  the 
street,  and  the  like.  Shortly  he  could  get  back  his  mem- 
ories more  quickly;  after  a  week  it  took  only  35  seconds  to 
remember  that  he  was  born  at  Paris.  However,  his  recollec- 
tion of  the  Trocadero  and  of  the  EifTel  Tower,  which  had 
come  back  to  him  in  November,  191 5,  was  lost  again  in 
April,  1916,  to  return  once  more  in  August.  December,  1915, 
he  could  not  write  to  dictation,  but  copied  writing  as  he  would 
a  design.  He  suddenly  felt  himself  able  to  write  in  the 
Morse  code  (he  was  a  telegrapher);  then  ordinary  writing 
returned.  February,  1916,  however,  he  had  forgotten  what 
the  Morse  code  was.  In  April,  he  was  taught  numbers. 
One  day  he  would  know  left  from  right,  but  had  forgotten  it 
by  evening. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  635 


Shell-explosion :  Comrade  killed :  Amnesia. 


Case  449.     (Gaupp,  April,  1915.) 

F.  K.,  a  23-year  old  soldier,  in  civil  life  a  turner,  of  Polish 
descent,  and  of  a  somewhat  nervous  and  easily  excitable  dis- 
position, early  in  August  went  from  Strassburg  into  the 
Vosges  and  Lorraine,  On  the  26th  a  number  of  shells  exploded 
near  him.  The  troop  was  excited  and  took  refuge  in  a  cellar. 
K.'s  best  friend  was  torn  to  pieces  by  a  shell.  When  his 
body  was  removed,  K.  felt  sick  and  lost  consciousness.  He 
arrived  at  the  clinic  in  Tubingen  in  a  stuporous  condition, 
by  hospital  train,  on  August  31,  19 14.  He  walked  weakly  to 
his  bed,  supported  by  two  men,  and  lay  in  the  bed,  apathetic 
and  reacting  to  questions  only  with  a  stare.  Things  put  in 
his  mouth  were  swallowed.     He  remained  motionless. 

Next  evening  he  answered  a  low  Yes  to  a  nurse's  question 
about  eating.  A  little  afterwards  he  said  he  supposed  he 
was  a  prisoner  in  the  enemy's  country.  A  little  later  he  got 
properly  oriented  but  still  did  not  know  how  he  had  come. 
September  2,  however,  he  was  much  clearer  and  said  he  had 
awakened  out  of  a  long  dream.  There  was  a  complete 
amnesia,  however,  from  the  moment  when  he  went  to  help 
remove  the  torn  body  of  his  friend  up  to  September  i. 
Memories  became  clearer  for  the  period  before  the  shell  ex- 
plosion. The  patient  became  very  lively,  talking  vividly  of 
war  experiences,  imitating  shell  hissing  with  an  expression 
of  intense  anxiety,  getting  accustomed  to  battle  scenes,  say- 
ing that  he  was  now  seeing  everything  again  as  If  real.  He 
remained  anxious  for  some  days,  complaining  of  weight  on 
his  chest  and  of  feelings  of  internal  restlessness  and  tension. 

Amnesia  for  the  period  of  August  26  to  September  i  re- 
mained; all  that  K.  could  add  to  the  stor>^  of  those  days 
was  that  he  had  been  thrown  sidewlse  for  some  distance  by 
the  air  pressure  of  the  shell. 

From  September  6  onwards,  he  grew  calmer  but  he  was 
still  very  labile,  given  to  lively  imaginings  and  emotion.  By 
the  middle  of  September  he  was  well  and  discharged  for 
garrison  duty. 


636  THE  DIAGNOSIS  OF   SHELL-SHOCK 


Shell-explosion :  Recurrent  amnesia. 


Case  450.     (Mairet  and  Pieron,  July,  1915.) 

A  man,  33,  had  suffered  shell-shock  early  in  December, 
1 9 14.  His  intervening  history  is  not  reported,  but  he 
showed  on  admission  to  the  service  of  Mairet  and  Pieron, 
May  5,  1915,  a  remarkable  amnesia.  There  was  a  complete 
cutaneous  anesthesia,  anosmia,  and  ageusia,  and  he  was  mute. 
He  lived  only  in  the  specious  present.  His  previous  life  was 
completely  abolished  for  him.  He  could  dress  himself,  eat, 
use  a  fork  and  spoon,  and  a  glass.  He  understood  ordinary 
words;  such  words  as  man,  woman,  day  and  night,  however 
had  no  meaning.  He  was  observed  for  15  months  and  pre- 
sented four  phases. 

In  phase  one,  there  was  a  measure  of  success  in  reeduca- 
tion, such  that  he  grew  able  to  recognize  a  few  persons,  to 
find  his  bed,  and  name  objects.  He  was  got  to  copy  writing, 
to  learn  the  alphabet,  and  to  say  a  few  words.  He  could  not 
write  from  dictation,  however.  Less  than  two  seconds  after 
looking  at  an  .4,  he  had  forgotten  how  it  looked  and  could 
not  trace  it.     This  first  phase  lasted  about  two  months. 

The  second  phase  began  with  fatigue,  headaches,  and  the 
rather  quick  effacement  of  all  he  had  relearned.  If  an 
errand  was  given  him  to  do,  he  would  run  to  do  it  before  he 
should  forget  it;  but  if  the  trip  required  more  than  4  or  5 
seconds,  he  had  to  stop,  not  knowing  what  to  do  with  the 
thing  in  his  hands.  He  was  still  able  to  recognize  4  or  5 
persons,  but  could  add  no  more  to  his  repertoire;  and  when 
one  of  them  had  been  absent  for  a  fortnight,  he  did  not 
recognize  him  on  his  return.  He  could  not  remember  the 
time  for  his  meals. 

The  third  phase  was  ushered  in  by  improvement  after 
vomiting;  his  speech  came  back  in  a  feeble  voice,  ,Novem- 
ber  16,  II  months  after  the  shock.  Reeducation  could  now 
be  undertaken  again.  He  easily  relearned  a  number  of 
things,  feeling  the  greatest  astonishment  at  his  new  acquire- 
ments as  to  the  sun  and  the  moon,  the  trees  and  the  flowers, 
and  the  like.     He  expressed  a  curiosity  to  see  his  own  home, 


THE  DIAGNOSIS  OF  SHELL-SHOCK  637 

but  when  he  went  thither,  he  could  recognize  nothing.  He 
wanted  to  get  back  home,  namely  to  the  hospital  where  he 
had  lived  all  his  life;  where,  in  fact,  he  had  been  born  from 
the  psychic  point  of  view. 

At  this  time  began  the  fourth  phase,  April,  19 16  —  a 
phase  of  decline  once  more,  in  which  a  large  portion  of  his 
acquisitions  were  again  lost  and  he  fell  back  to  his  condition 
in  the  second  phase. 

See  discussion  under  Case  353  and  under  Case  367.  Re 
confusional  mental  states,  Roussy  and  Lhermitte,  after  dis- 
tinguishing stuporous  confusion  from  simple  confusion,  go 
on  to  differentiate  what  they  call  obtusion  (see  also  dis- 
cussion under  Case  353).  These  authors  say  that  Regis, 
in  common  with  most  psychiatrists,  fails  to  distinguish  the 
slow  thinking  and  amnesia  of  true  mental  confusion  from  the 
temporal  and  the  spatial  disorientation  that  characterize  the 
so-called  obtusion.  Of  course,  in  all  attacks  of  confusion, 
both  attention  and  memory  are  affected,  but  there  are  spe- 
cial types  in  which  attention  defects  and  memory  defects 
stand  out  in  relief.  The  first  of  these  types  is  the  aprosexic 
type  with  birdlike  movements,  described  by  Chavigny  (see 
for  an  example,  Case  446).  This  aprosexia  may  be  combined 
with  mutism,  deafness,  or  convulsions.  The  form  of  con- 
fusional disease  in  which  amnesia  is  the  out-standing  feature 
is  due  to  toxic  or  infectious  disease,  or  is  a  Korsakow  phe- 
nomenon, i.e.,  in  the  psychiatry  of  peace  times;  but  the 
war  has  brought  out  amnestic  confusion  in  other  states 
than  the  toxic,  infectious,  and  alcoholic  states  (Regis, 
Chavigny,  Dumas,  Roussy  and  Lhermitte).  The  amnesia 
may  be  incomplete,  a  sort  of  dysmnesia,  or  twilight  memory, 
but  as  a  rule,  the  amnesia  is  lacunar.  The  toxic  and  in- 
fectious amnestic  confusions  have  a  loss  of  memory  for  events 
following  the  onset,  but  these  war  cases  of  amnestic  con- 
fusion have  the  loss  of  memory  running  back  far  into  the 
patient's  past,  slipping  from  the  mind  his  name,  his  parent- 
age, age,  and  vocation.  Instead  of  being  like  the  toxic  con- 
fusional amnesia,  an  anterograde  amnesia  of  fixation,  the 
Shell-shock  amnesia  is  apt  to  be  antero-retrograde.  These 
antero-retrograde  amnesias,  whether  due  to  emotion  or  to 


638  THE  DIAGNOSIS   OF   SHELL-SHOCK 

strong  physical  shock,  may  sometimes  leave  in  sharp  relief 
the  recollection  of  the  shock  or  event  itself  which  initiated 
the  amnesia.  Meanwhile  the  patient  does  not  forget  auto- 
matic actions  of  dressing,  reading,  writing,  and  the  like. 
The  amnesia  may  be  very  selective,  imitating  aphasia,  word 
blindness,  letter  blindness,  agraphia,  and  the  like.  All  this 
is  part  of  the  hallucinatory  form  of  mental  confusion  which 
Regis  describes  as  oniric  delirium  (see  for  oniric  delirium, 
discussion  under  Case  333). 

Lepine  distinguishes  amongst  the  confusions,  five  forms  as 
follows:  Simple  confusion,  hallucinatory  confusion,  acute 
delirium,  stuporous  confusion  (under  which  Lepine  also  con- 
siders the  battle  hypnosis  of  Milian,  see  Case  365,  and 
Roussy's  narcolepsy),  and  amnestic  confusion.  All  these 
phenomena  from  the  clinical  point  of  view  are  connected 
with  an  acute  and  fleeting  insufficiency  of  the  most  delicate 
or,  as  it  were,  psychic  portions  of  the  cerebral  cortex,  the 
delirium,  so  to  speak,  being  activity  of  the  unconscious, 
whereas  a  confusion  is  due  to  a  clouding  of  the  centre  O  of 
Grasset's  polygon. 


THE  DIAGNOSIS    OF    SHELL-SHOCK  639 


Soldier's  heart,  both  neurotic  and  organic. 


Case  451.     (MacCurdy,  July,  191 7.) 

A  territorial,  19,  who  had  enhsted  in  January  1914,  reached 
France  in  September,  1916.  He  was  of  neurotic  make-up 
(night  terrors,  fear  of  dark,  giddiness  in  high  places,  fear  of 
tunnels,  enuresis  until  10  years,  worry  about  seminal  emis- 
sions), and  had  always  had  a  tendency  to  short  wind.  En- 
listing at  16,  he  found  it  hard  carrying  his  pack  at  first  but 
soon  grew  stronger.  The  trench  life  was  distasteful.  He 
began  to  wish  that  he  might  be  killed,  or  at  all  events  re- 
moved from  the  trenches.  Pains  developed  under  the  heart, 
with  shortness  of  breath,  palpitation,  dizziness,  and  faint 
feelings.  The  man  connected  these  heart  symptoms  with 
what  he  called  his  weakness  of  gall  bladder  (namely,  enuresis) . 
He  was  several  times  sent  off  duty  for  heart  treatment. 
After  three  months  in  and  out  of  hospital,  he  got  trench  foot, 
was  sent  to  England,  and  transferred  to  a  special  heart  hos- 
pital. Here  the  pulse  test  was  positive,  in  that  the  rate  did 
not  diminish  as  it  normally  does  after  two  minutes'  rest. 
After  graduated  exercises  for  several  months,  the  pulse  test 
had  become  negative  and  the  heart  had  gradually  improved 
from  the  organic  standpoint.  The  patient,  however,  in- 
sisted that  his  heart  trouble  was  as  bad  as  ever,  and  was 
probably  consciously  hoping  that  his  symptoms  might  per- 
sist. 

Re  soldier's  heart,  Abrahams  classifies  cases  that  come  to 
the  military  surgeon  for  heart  symptoms  as  {a)  functional 
fatigue  cases;  (b)  nicotine  and  drug  cases;  (c)  organic  heart 
disease  and  Graves'  disease;  {d)  the  true  soldier's  heart, 
occurring  in  men  with  a  neurasthenic  soil  that  lose  control 
of  the  vasomotors  and  inhibitors  of  the  heart. 


640  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Soldier's  heart,  neurotic. 


Case  452.     (MacCurdy,  July,  191 7.) 

An  Australian  gunner,  35,  of  a  neurotic  make-up  (night 
terrors;  horror  of  blood;  fear  of  thunderstorms,  high  places, 
tunnels,  horses;  shy  with  both  sexes),  benefited  by  military 
training  physically,  but  remained  as  neurotic  as  ever.  On 
the  way  to  his  first  service  in  Egypt,  he  feared  shipwreck, 
and  in  Egypt  was  troubled  by  the  weather  and  occasional 
palpitations  and  sinking  feelings.  He  was  transferred  to 
the  French  front,  May,  1916.  He  was  terrified  and  de- 
pressed under  shell  fire,  and  horrified  by  blood.  Peculiar 
sinking  sensations  or  feelings  that  the  soul  was  leaving  the 
body  came  to  him  as  he  was  going  off  to  sleep;  from  which 
he  woke  at  times  with  sudden  starts.  Later  he  had  night- 
mares of  things,  mainly  shells,  falling  on  him.  He  worried, 
wanted  death,  and  thought  of  suicide.  In  May,  191 7,  he 
was  blown  off  his  feet  by  a  shell.  Thereafter  he  began  to 
feel  that  shells  were  being  especially  aimed  at  him,  and  four 
days  later  got  a  pain  in  the  side,  and  began  to  tremble  and 
breathe  with  difficulty,  as  if  his  throat  were  swelled  up  and 
he  were  going  to  choke.  He  ascribed  this  to  gas.  The 
bombardier  finally  sent  him  back  to  a  hospital,  where  he 
grew  weaker  and  screamed  aloud  on  being  awakened  by  his 
dreams.  After  six  weeks  in  a  special  heart  hospital,  all  the 
symptoms  cleared  up  except  the  choking  feelings  and  fear  of 
instant  death.  Organically  the  man  appeared  normal.  An 
initial  pulse  of  96  ran  up  to  168  after  exercise,  and  down  to 
84  after  two  minutes'  rest. 

Re  soldier's  heart,  Abrahams  speaks  of  sundry  hypotheses 
that  he  regards  as  erroneous.  Soldier's  heart  has  been 
thought  to  be  (a)  athlete's  heart;  others  regard  it  as  {b)  a 
toxemic  condition,  possibly  of  bacterial  origin;  {c)  hyper- 
thyroidism (a  larval  form  of  Graves'  disease  has  been  in- 
criminated);  {d)  excessive  cigarette  smoking;  and  {e)  defi- 
ciency of  buffer  salts  in  the^blood,  have  been  proposed  by 
other  authors. 


THE   DIAGNOSIS   OF    SHELL-SHOCK  64I 

Gallavardin  has  especially  studied  the  tachycardial  cases 
revealed  by  the  war,  cases  in  which  auscultation  is  frequently 
unable  to  detect  aught.  These  tachycardiacs  are  often 
hypertensive.     Sedentary  service  should  be  found  for  them. 

Re  pulse  i68  after  exercise,  Gallavardin  found  8  per  cent 
of  500  non-organic  and  non-tuberculous  cases  to  run  up 
from  150  to  175  (125  to  150  in  27  per  cent;  100  to  125  in 
37  per  cent;   75  to  100  in  26  per  cent;   50  to  75  in  2  per  cent). 

Re  cardiac  neuroses,  Brasch  points  out  that  cardiac  neu- 
roses in  the  male  in  war  time  have  found  a  strange  new  asso- 
ciation with  hyperesthesia  of  the  skin.  The  patients  show^ed 
dermatographia  and  hyperreflexia.  The  hyperesthetic  zones 
of  Head  and  ^lackenzie  were  found  by  Brasch  in  all  cases  of 
organic  cardiac  disease,  but  also  in  two  cases  of  cardiac 
neurosis  in  hysterics. 

Moore  calls  attention  to  somewhat  similar  phenomena  in 
the  somatic  group  of  nervous  and  depressed  cases  found  in 
the  war.  These  patients  are  fatigued,  exhausted,  sleepless, 
tremulous,  vascular,  and  cardiac  cases,  with  dermatographia, 
areas  of  paresthesia,  and  pains  in  the  neighborhood  of  wound 
scars. 


642  THE   DIAGNOSIS   OF   SHELL-SHOCK 


War   Strain;    Shell-shock:    Hysteria  (question  of 
malingering). 


Case  453.     (Myers,  March,  1916.) 

A  sergeant,  32,  with  11  years'  service  and  eight  months' 
service  in  France,  was  admitted  to  a  base  hospital  for  inquiry 
as  to  possible  malingering.  It  seems  that  he  had  taught  in 
an  army  school  for  seven  years  before  the  war.  He  found 
heavy  marches  in  France  too  much  for  him  and  fainted  in 
the  retreat  from  Mons  and  during  the  fighting  on  the  Aisne, 
where  he  had  reported  sick  for  dysentery.  The  field  am- 
bulance where  he  was  treated  was  near  the  shell  fire,  and  a 
shell  knocked  him  into  a  ditch.  The  ambulance  had  to  move 
to  a  cave.  Thereafter  the  patient  suffered  from  tremor  when 
spoken  to  or  when  watched.  After  discharge,  he  was  em- 
ployed as  a  dispatch  rider  on  a  motor  cycle,  but  after  three 
months  lost  his  nerve  for  this  work  and  took  charge  of  fatigue 
parties.  He  found  the  work  too  much  for  him.  He  had  been 
a  total  abstainer.  Finally  the  malingering  charge  was 
brought  up. 

The  patient  was  nervous,  delicate-looking,  with  widely 
dilated  pupils,  prominent  eyeballs,  tremor  of  right  arm,  and 
pulse  of  102.  The  tremor  was  markedly  lessened  when  he  was 
alone,  and  was  somewhat  under  control.  He  felt  that  his 
memory  was  defective,  and  tests  demonstrated  the  defect. 

In  hospital  patient  slept  better,  the  pupils  grew  smaller,  the 
pulse  rate  diminished.  There  was  a  reduction  in  sensibility 
to  pain  over  the  right  side  of  the  head  and  body  and  over 
the  right  limbs.  A  prick  of  the  right  arm  or  leg  was  described 
as  a  finger  touch.  There  was  also  almost  complete  hemi- 
anosmia  and  complete  hemi-ageusia  on  the  right  side.  Visual 
acuity  was  diminished  on  the  right,  and  there  was  general 
limitation  of  right  field;  left-sided  vision  and  field  normal. 

After  a  month  in  hospital  at  home  and  two  months'  leave, 
the  patient  was  discharged  no  longer  physically  fit  for  ser- 
vice.    He  is  now  weak  physically  and  mentally,  subject  to 


THE  DIAGNOSIS  OF   SHELL-SHOCK  643 

severe  headaches,  and  tremulous,  especially  in  the  right  arm, 
when  tired. 

Re  malingering,  Sicard  denies  the  existence  of  unconscious 
malingerers  (presumably  regarding  this  phrase  as  a  figure 
of  speech  in  relation  to  hysteria),  and  divides  malingering 
into  a  creative  and  an  acquired  form.  The  simulateur  de 
creation  assumes  attitudes  and  symptoms  to  attract  atten- 
tion or  pity;  the  simulateurs  de  fixation  having  been  sick 
in  the  beginning,  perpetuate  their  disease,  in  brief,  crystal- 
lize their  neuroses.  The  fixateur  may  be  very  realistic  in 
all  this,  seeing  that  he  has  known  from  his  own  experience 
what  a  real  disease  is.  The  formula  runs:  The  simtdateur 
de  creation  improvises;  the  simulateur  de  fixation  repeats. 

According  to  Mott,  malingering  in  the  form  of  an  assumed 
Shell-shock  is  not  uncommon  amongst  soldiers,  and  is  rather 
hard  to  distinguish  from  a  neurosis  developing  on  the  basis 
of  an  idee  fixe. 

Ballet's  definition  of  simulation  is  "a  subjective  or  objec- 
tive disorder  which  the  patient  invents  with  the  idea  of 
voluntarily  and  consciously  misleading  the  observer." 
Closely  related  to  simulation  is  exaggeration  or  prolonga- 
tion, conscious  or  intentional,  of  a  real  disorder.  Babinski 
states  that  cases  of  genuine  simulation  are  very  rare,  and 
that  the  subject  under  suspicion  should  be  given  the  benefit 
of  the  doubt.  Especially  the  word  simulation,  or  similar 
words,  should  not  be  uttered  in  the  presence  of  the  patient. 
Practically  speaking,  psychotherapy  applied  as  in  cases  of 
hysteria  may  often  cure  the  simulator  and  the  exaggerator. 


644  "^^^  DIAGNOSIS   OF   SHELL-SHOCK 


The  officer  who  could  not  kick. 


Case  454.     (Mills,  January,  1917-) 

An  officer  had  had  a  bullet  in  the  right  calf,  of  which 
nothing  was  evident  months  later  but  small  scars  of  entrance 
and  exit.  Nevertheless  he  complained  of  pain,  especially 
after  walking,  and  of  inability  to  dorsiflex  the  foot  beyond 
a  certain  point.  No  wasting  could  be  found  and  no  impair- 
ment of  sensation.  The  muscles  were  faradically  normal. 
Mills  thought  the  symptoms  were  exaggerated  and  so  re- 
marked to  the  officer. 

Under  anesthesia,  however,  the  dorsifiexion  also  proved 
to  be  impossible,  and  after  exerting  considerable  force, 
Dr.  Dunhill  was  able  to  rupture  a  massive  fibrous  band  of  ad- 
hesions that  had  prevented  extension.  The  officer  made  a 
good  recovery. 

Dr.  Mills  confessed  his  error  to  the  officer  who  had  naturally 
resented  the  suggestion  of  malingering.  The  officer  forgave 
him. 

Re  malingering,  Moore  states  that  no  diagnosis  of  malin- 
gering should  be  made  without  the  most  careful  examina- 
tion and  consideration  of  the  individual  as  such,  on  account 
of  the  fact  that  the  erroneous  diagnosis  dejects  the  patient 
and  postpones  recovery.  It  is  particularly  unwise  to  term 
the  trouble  "imaginary,"  or  to  talk  about  "suggestion"  or 
use  similar  terms  in  the  presence  of  the  patient. 

Craig  has  found  very  few  cases  of  actual  malingering  and 
states  that  tremors  and  paroxysms  are  often  mistaken  there- 
for. Bispham  remarks  that  few  malingerers  are  found  among 
the  patients  of  a  doctor  who  is  known  to  be  a  thorough 
examiner. 

Re  orthopedic  cases  like  Case  454,  Gleboff  remarks  upon 
the  simulation  of  joint  affections  and  upon  methods^of  sur- 
prising the  malingerers  into  sudden  movements  made  in  obe- 
dience to  request  in  the  course  of  medical  examination. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  645 


Doubtful  accounts  by  patient  concerning  arm  pal- 
sy :  Incorrect  diagnosis  of  simulation. 


Case  455.     (Voss,  November,  1916.) 

A  volunteer,  18,  just  before  the  war  had  a  fall  in  which 
apparently  he  injured  his  skull.  In  December,  19 14,  he  hurt 
his  left  forearm.  About  this  injury  he  sometimes  said  he 
fell  in  a  storming  attack  in  a  trench  and  broke  his  arm,  and 
again  he  said  his  arm  had  been  smashed  by  stones  from  a 
falling  house.  From  that  time  forward  there  was  paralysis 
of  the  left  forearm  with  flexor  contracture.  May,  19 15, 
slight  hypesthesia  could  be  demonstrated  on  the  ulnar  side 
of  the  arm,  suggesting  ulnaris  injury.  There  were,  however, 
no  considerable  electrical  changes. 

Six  months  later  the  man  was  sent  up  with  a  suspicion  of 
simulation.  In  the  meantime  the  contracture  had  resolved 
and  there  was  a  typical  hysterical  paralysis  with  all  signs  of 
neurosis.  Six  months  later  he  was  well  enough  to  be  ex- 
amined for  military  service. 

Here  was  a  case  In  which  the  incorrect  data  offered  by  the 
patient  himself  as  to  the  origin  of  his  paralysis  gave  rise  to 
the  suspicion  of  simulation,  whereas,  as  a  matter  of  fact,  the 
man  was  clearly  hysterical. 

Re  incorrect  data  supplied  by  the  patient  to  his  own  dis- 
advantage, Lumsden  remarks  on  the  great  difficulty  of  diag- 
nosis in  cases  where  hysteria  and  malingering  have  been 
combined,  and  Morselli  states  that,  If  the  doctor  has  really 
made  up  his  mind  that  the  man  is  shamming,  he  should  send 
him  back  to  the  fighting  line  at  once. 


646  THE  DIAGNOSIS  OF   SHELL-SHOCK 


Forearm  wound :  Hysterical  edema? 


Case  456.     (Lebar,  July,  1915.) 

A  corporal,  26,  formerly  a  farmer,  was  struck  in  the 
forearm  by  a  shell  fragment  on  the  mid-portion  of  the  radial 
border.  The  wound  was  slight  (the  fragment  entering  and 
emerging  hardly  2  cm.  apart)  but  bled  profusely,  according 
to  the  patient,  who  was  evacuated  next  day  but  one  to  a 
hospital  in  the  interior.  By  this  time  the  right  hand  was 
swollen,  nor  could  any  movement  of  hand  or  fingers  be  made. 
Massage,  mechanotherapy,  passive  movements  did  no  good.  I 

The  man  entered  the  neurological  center  of  the  Eighth 
Region,  July  7,  191 5,  when  there  were  already  a  few  skin 
changes  with  dorsal  thinning  and  palmar  thickening.  There 
w^as  cutaneous  anesthesia  not  only  of  hand  and  fingers  but  of 
the  forearm  to  the  elbow,  and  this  anesthesia  included  heat 
and  cold.  Position  sense  was  preserved.  There  was  no 
evidence  of  atrophy  except  for  the  skin  changes.  An  elec- 
trical examination  showed  normal  conditions. 

July  13,  a  sealed  bandage  was  put  on,  but  at  the  end  of 
five  days  the  hand  looked  as  before.  July  19,  a  new  treat- 
ment was  announced  to  the  patient.  With  a  hot  needle  a 
number  of  pricks  were  made  on  the  dorsal  surface  of  the 
hand  and  a  few  c.c.  of  fluid  were  withdrawn  (containing  a 
slight  amount  of  albumin  and  a  few  lymphocytes),  whereupon 
a  dry  bandage  was  put  on.  The  next  day  a  few  finger  and 
thumb  flexion  movements  could  be  made  and  sensation  had 
returned.  Sensation  completely  returned  July  21.  The 
flexion  movements  were  still  incomplete,  by  reason  of  the 
edema  and  dryness  of  the  skin.  However,  July  22,  flexion 
was  better  and  the  swelling  had  gone  down  sixty  per  cent. 
Jacquet's  biokinetic  treatment  (active  gymnastics  of  the 
hand  and  fingers)  w^as  given  for  four  hours.  July  25,  the 
edema  had  greatly  diminished  and  normal  motion  had  re- 
turned. 

Examination  excluded  renal  disease.  There  was  no  sign 
indicating  phlegmon.     Quincke's  disease  had  other  features. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  647 

Fraudulent  application  of  a  bandage  might  be  considered, 
but  the  course  of  the  disease  under  sealed  conditions  seems 
to  exclude  this  hypothesis  also.  May  it,  therefore,  not  be  a 
case  of  hysterical  edema? 

Re  hysterical  edema,  see  remarks  under  Case  407.  In 
the  case  above,  of  Lebar,  Babinski  calls  attention  to  the 
fact  that  the  edema  and  the  contracture  diminished  though 
they  did  not  entirely  disappear  after  the  scarifications.  This 
physical  treatment  did  not  act,  according  to  Babinski,  wholly 
as  a  matter  of  suggestion,  and  he  fears  that  some  cases  of 
so-called  hysterical  edema  are  really  cases  of  physiopathic 
vasomotor  disorder;  in  fact,  three  of  the  cases  published 
(and  amongst  them,  the  present  case  of  Lebar),  were  cases 
of  edema  associated  with  contracture  and  developing  in  an 
injured  limb.  To  prove  a  case  of  anything  to  be  hysterical 
is,  of  course,  according  to  the  Babinski  school,  to  submit  it 
to  a  therapeutic  test  and  cure  it  by  suggestion. 


648  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Shell  Splinters  in  head :  Suspicion  of  (a)  simulation, 
(6)  hysteria.     Case  actually  surgical. 


Case  457.     (Voss,  November,  1916.) 

A  man,  injured  by  shell  fragments  in  the  head  and  sus- 
taining fracture  of  both  arms  and  a  thigh,  got  well  of  his 
wounds,  but  fell  into  a  nervous  state  with  headache  and 
dizziness.  He  was  given  prolonged  observation  psychiat- 
rically  and  then  sent  back  to  the  front  as  fit  for  service,  but 
was  shortly  returned  to  hospital  and  sent  to  Cologne  under 
the  suspicion  of  simulation. 

The  picture  was  of  unilateral  increase  of  tendon  reflexes, 
accelerated  pulse,  disorder  in  the  intake  of  ideas,  difficulty  in 
finding  words  and  delayed  associations.  His  gait  suggested 
a  psychogenic  disorder.  X-ray  showed  two  shell  fragments 
in  the  vault  of  the  skull. 

According  to  Voss,  it  is  a  sad  fact  that  victims  of  skull 
injuries  are  frequently  charged  with  simulation  or  exagger- 
ation. ,  In  the  above  instance,  moreover,  this  charge  was 
undoubtedly  inaccurate. 

Re  simulation,  see  remarks  under  Case  453.  Re  neuro- 
logical cases,  the  Neurological  Society  of  Paris  sent  to  the 
War  Ministry  a  special  note  pointing  out  how  tardy  was 
the  reference  of  sundry  neurological  cases  to  the  special 
neurological  service.  They  pointed  out  how  important  it 
was  to  send  to  these  special  services  all  cases  of  bullet  and 
shrapnel  lesions. 

Re  the  malingering  question,  there  is  a  wide  divergence  of 
opinion,  even  amongst  experienced  workers  in  the  same  city. 
The  Jate  Professor  Dejerine  said  he  had  not  seen  a  single 
case  of  malingering.  In  fact,  he  thought  that  malingering 
amongst  soldiers  and  amongst  injured  industrial  workers  had 
been  much  exaggerated.  Marie,  however,  working  in  the 
examination  of  many  surgical  cases,  found  malingering  rela- 
tively common.  Amongst  forty  of  his  cases,  he  regarded 
at  least  nine  as  malingerers  or  exaggerators. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  649 


"Sciatica,"   torticollis,   stiff   arm:   The    desire   to 
avoid  active  service  plus  fiinctional  disease. 


Case  458.     (Collie,  January,  1916.) 

A  man  enlisted  September,  19 14,  went  to  France  after  six 
months'  training,  immediately  put  himself  on  sick  list,  and 
was  admitted  to  a  base  hospital :  Diagnosis,  sciatica.  Later, 
he  ceased  complaining  of  sciatica  and  developed  spastic  torti- 
collis. He  was  sent  back  to  England,  was  treated  with 
radiant  heat  and  so  on,  and  was  eventually  sent  to  the  Royal 
Bath  Hospital  at  Harrowgate. 

He  recovered  from  torticollis  after  six  weeks'  treatment; 
but  then  developed  a  spasmodic  contracture  of  the  right 
shoulder  and  forearm.  He  was  massaged  for  this  and  also 
given  high  frequency  treatment.  Then  came  two  transfers 
(massage) . 

Early  in  December,  191 5,  he  came  under  Collie's  obser- 
vation. He  then  showed  right  wrist  bent  at  right  angles  to 
the  forearm;  hand  tightly  clenched,  so  firmly  that  it  seemed 
as  if  the  wrist  were  ankylosed.  The  case  was  obviously  a 
functional  one.  The  man  refused  to  enter  hospital  at  Collie's 
suggestion.  He  was  sent  to  the  Maida  Vale  Hospital.  Pre- 
viously he  tried  to  persuade  the  medical  ofhcer  that  further 
hospital  treatment  was  unnecessary,  stating  that  he  was 
now  able  to  straighten  his  arm  and  that  he  was  applying  a 
splint  to  keep  it  straight.  He  progressed  slowly  in  the  in- 
stitution. Told,  if  he  would  recover  within  fourteen  days,  he 
would  be  classified  "for  home  service  only" — before  the 
fourteen  days  were  up,  he  had  suspended  his  weight  on  a 
trapeze  and  pulled  himself  up  to  his  chin  on  it;  had  also 
lifted  a  28-lb.  weight  with  his  paralyzed  hand.  In  short,  he 
wholly  recovered.     He  is  now  doing  duty  with  his  unit. 

Collie  says  this  is  not  deliberate  malingering  but  a  mix- 
ture of  functional  disease  and  an  obvious  desire  to  avoid 
active  service.  When  he  appeared  before  the  board  for  a 
final   decision,    there   was   a  tendency   to    assume   the   old 


650  THE   DIAGNOSIS   OF   SHELL-SHOCK 

paralyzed  position  until  he  was  sharply  called  to  order,  when 
his  arm  assumed  normal  position. 

Conclusion :  The  direct  personal  treatment  of  his  mental 
condition  and  an  appeal  to  his  lower  instincts  were  imme- 
diately curative  and  of  much  more  value  than  the  radiant 
heat  or  high  frequency  treatment. 

Re  Collie's  case,  Russel  finds  surprisingly  large  numbers  of 
malingerers;  he  found  many  at  the  time  of  the  battles  at 
Loos.  It  was  particularly  easy  in  cases  of  epilepsy  to  dem- 
onstrate a  close  relation  between  hysteria  and  malingering. 
In  the  psychogenesis  of  these  conditions,  Russel  emphasizes 
the  initial  element  of  deception,  which  soon  enormously  in- 
creases either  through  the  patient's  convictions  of  his  ability 
to  deceive  or  through  a  process  of  autosuggestion.  Cases  of 
semi-malingering  are  not  uncommon.  In  England,  Russel 
found  more  cases  of  a  clearly  psychogenic  nature;  yet  in 
these,  also,  there  was  always  primarily  an  element  of  decep- 
tion. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  65 1 


Yes-No  test  of  value  re  anesthesia. 


Case  459.     (Mills,  January,  191 7.) 

The  "Yes-No  "  test  proved  of  special  value  in  the  case  of 
an  Australian  private.  Shortly  after  landing  at  Gallipoli 
this  man  had  a  bullet  graze  his  ankle  and  fell  some  thirty  feet 
over  the  bow  of  a  ridge.  He  was  picked  up  unable  to  move 
his  legs  and  insensitive  therein. 

The  paraplegia  and  anesthesia  lasted  three  months. 
"  Fracture  dislocation  of  the  dorsal  spine  "  was  the  diagnosis 
made,  and  laminectomy  was  even  contemplated.  The 
sphincter  reflex  was  normal  and  there  was  no  atrophy,  no 
rigidity  and  no  reflex  disorder.  Asked  to  say  "  no  "  when  he 
could  not  feel  a  pin-prick  and  "  yes  "  when  he  did  feel  it,  he 
replied  "  no  "  to  each  prick  to  the  anesthetic  area  and  changed 
his  reply  to  "  yes  "  when  the  sensitive  parts  of  the  body  were 
examined.  At  another  time  the  answers  were  found  not  to 
correspond  with  those  given  before. 

The  soldier  was  assured  that  he  would  get  well  and  that 
as  soon  as  he  could  walk  he  would  be  boarded  and  returned  to 
Australia. 

After  a  number  of  weeks  he  became  able  to  walk. 


Arabian  fever. 


Case  460.     (RoussY,  April,  191 5.) 

An  Arab  fell  on  his  knee,  one  day  in  the  trenches.  A  con- 
tracture of  the  left  arm,  with  great  pain,  and  a  temperature  of 
38  to  40  degrees,  with  hemoptysis,  developed.  This  man  had 
been  considered  tuberculous.  One  day,  however,  the  ther- 
mometer went  up  to  41  degrees.  It  was  discovered  that  he 
took  artificial  means  to  push  the  mercury  up,  and  that  the 
spitting  of  blood  was  voluntary.  All  these  phenomena  dis- 
appeared after  he  was  put  in  the  guardhouse  for  24  hours. 


6S2  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Shrapnel  scratch  of  head:  Hysterical  amaurosis 
"  ?  "  On  isolation  in  a  dark  room,  the  patient  began 
to  see  light ! 


Case  461.     (Briand  and  Kalt,  February,  191 7.) 

A  man  may  seek  to  exaggerate  an  anomaly  of  his  eye  which 
had  existed  before  the  war,  in  order  to  live  comfortably  far 
from  the  front. 

A  soldier  sustained  a  slight  scratch  from  a  shrapnel  bullet 
in  front  of  the  left  ear,  which  scarred  over  in  a  few  days. 
The  soldier  said,  however,  that  the  bullet  had  gone  through 
his  skull  and  a  few  hours  after  his  wound  said  he  could  not 
see.  Sent  to  the  hospital  he  continued  to  say  he  was  blind 
and  finally  brought  up  in  an  asylum  for  the  blind  near  Lyons 
where  he  was  taught  to  cane  chairs  and  to  write  in  Braille. 
This  happened  in  July,  191 5. 

In  October  he  was  sent  to  the  Hospital  at  Quinze-\^ingt 
where  a  diagnosis  of  hysterical  amaurosis  was  made  with  a 
large  interrogation  point.  He  was  then  sent  to  Brequet 
where  there  was  a  section  reserved  for  disciplinary  cases  and 
very  nervous  cases  not  wanting  to  get  well,  a  service  under 
the  charge  of  Roubinowitch. 

The  soldier  escaped  with  a  comrade  and  eventually  reached 
\'al-de-Grace  where  the  diagnosis  of  hysterical  amaurosis 
was  again  made.  Examinations  several  times  showed  that 
there  was  nothing  abnormal  about  the  eyes  except  that  the 
eyelids  presented  habitual  fibrillary  movements  (antebellum) . 

The  eyelids  passively  opened,  would  remain  open  for  a  few 
minutes  and  then  close.  There  was  no  winking  of  the  eye  to 
a  light,  yet  the  pupil  preserved  its  reflex  power. 

Vision  was  abolished,  however,  the  soldier  said.  He  was 
without  any  other  motor  or  sensory  disorder.  Much  sym- 
pathy was  given  to  the  poor  blind  soldier.  People  were 
much  astonished  when  the  chief  of  the  ophthalmological  ser- 
vice had  the  man  isolated  in  a  dark  room.  Three  weeks 
later  the  man  had  begun  to  see  the  light  a  little.     A  week  later 


THE  DIAGNOSIS   OF   SHELL-SHOCK  653 

the  eyes  remained  open  without  the  necessity  of  having  the 
lids  raised  by  the  fingers,  and  vision  returned. 

Re  amaurosis,  Parsons  explains  the  blindness  which  may 
remain  after  consciousness  returns  following  Shell-shock,  as 
a  condition  in  which  the  lower  visual  paths  are  carrying  on 
their  functions  normally.  For  example,  the  pupillary  reac- 
tions are  preserved.  The  condition  is  not  unlike  that  found 
in  amaurosis  of  uremia,  and  Parsons  has  found  it  in  children 
with  posterior  basic  meningitis.  For  Parsons,  therefore,  the 
block  occurs  in  the  higher  centers  above  the  thalamus,  possibly 
in  the  synapses  of  the  optic  radiation  fibers.  Ormond  states 
that  the  true  cases  of  concussion  blindness  invariably  pass 
through  phases  of  great  discomfort;  whereas  the  malin- 
gerers are  without  such  discomfort.  Medical  suggestion,  also, 
has  a  powerful  effect  here,  and  may  actually  retard  recovery. 


654  THE  DIAGNOSIS  OF   SHELL-SHOCK 


A  newspaper  cure. 


Case  462.     (SiCARD,  October,  1915.) 

Sicard  read  in  a  French  newspaper  a  story  to  the  effect 
that,  at  two  o'clock  in  the  afternoon,  a  soldier  had  fallen 
on  the  sidewalk  between  Nos.  40  and  42  Boulevard  de  Liberte, 
in  a  nervous  crisis.  The  people  ran  and  picked  him  up. 
When  he  came  to,  he  was  very  joyful,  perceiving  that  the 
shock  had  given  him  back  his  speech,  which  he  had  lost  the 
August  previous.  This  soldier,  the  newspaper  continued, 
became  deafmute  through  the  explosion  of  a  bomb  in  a  fight 
in  Upper  Alsace.  "  The  brave  soldier  is  most  happy  over 
the  unexpected  result."  The  newspaper  went  on,  "  We  con- 
gratulate him  sincerely,  as  well  as  the  people  who  assisted 
him."  He  was  the  more  contented  that  he  had  gotten  well 
because,  the  soldier  said,  he  would  now  be  able  to  go  back 
among  his  comrades  to  fight  with  the  Boches! 

Now,  in  point  of  fact,  Sicard  had  dealt  with  this  soldier 
the  morning  of  the  day  in  question.  He  had  been  simu- 
lating mutism  for  ten  months,  and  finally  told  Sicard  that 
he  would  like  to  leave  that  afternoon  as  he  felt  cure  coming. 
Sometime  after,  he  wrote  a  letter  of  profuse  thanks  for  the 
benefits  received,  and  said  he  did  not  deserve  to  avoid  court- 
martial.  He  also  said  that  he  was  going  to  do  everything 
he  could  to  justify  himself.  Incidentally,  he  kept  his  word 
and  an  officer  in  his  regiment  later  gave  him  an  enthusiastic 
recommendation. 

Re  malingering,  see  discussion  concerning  simulateurs  de 
creation  and  simulateurs  de  fixation  under  Case  453. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  655 


Deaf  mutism:  Explained  by  patient  as  malingering. 


Case  463.     (Myers,  September,  1916.) 

A  pure  malingerer,  of  set  purpose,  initiates  a  quasipatho- 
logical  condition  which  he  will  discard  when  he  has  gained  his 
end  or  when  he  is  assured  that  he  is  unobserved.  Malinger- 
ing in  the  field  of  speech  is  rare.  A  private,  26,  one  year  in 
service,  three  months  in  France,  entered  a  base  hospital, 
deaf  mute  for  nine  weeks.  He  wrote:  "  I  should  be  very 
happy  if  you  can  do  anything  for  me.  I  cannot  give  a  very 
clear  account  of  what  happened,  as   it   is   sometime   since. 

I  remember  retiring  from  Hill with  some  more  to  some 

trenches,  and  in  the  open  we  were  shelled  and  I  lost  touch 
with  our  chaps  or  else  they  were  killed.  I  remember  a  great 
concussion  and  finding  myself  on  the  ground,  and  a  soldier 
dragged  me  up  and  we  ran  for  the  trench.  I  was  very  thirsty 
and  I  ran  down  the  trench  to  get  some  water.  I  met  one  of 
our  chaps  and  tried  to  ask  him  for  some,  and  I  could  not 
make  him  understand.  He  only  smiled  at  me.  The  man  who 
picked  me  up  took  me  to  an  officer  who  was  sitting  on  the  edge 
of  the  trench  and  tried  to  make  me  understand,  and  then 
he  sent  me  with  this  man  to  a  dressing  station,  and  from  there 
I  have  been  to  different  places,  the  names  of  which  I  do  not 
know,  except  the  last  place.  No.  —  Convalescent  Camp. 
I  have  been  there  about  two  months " 

He  seemed  anxious  to  get  well.  He  could  not  understand 
what  was  said.  Induced  anesthesia  caused  no  phase  of 
excitement,  and  the  patient  failed  to  regain  his  speech. 
He  was  evacuated  to  England.  Three  months  later  the 
patient  thence  wrote  the  following  confidential  letter  from  a 
Convalescent  Home.     "  Sir,  —  I  regret  very  much  to  inform 

you  that  I  was  imposing  upon  you. 1  may  state  that  I 

was  physically  unfit  for  the  Front. During  the  whole 

time  of  training  my  pay  was  chiefly  spent  in  tonics  and  drugs, 
but  I  kept  going  as  I  was  determined  to  see  what  it  was  like 

at  the  Front. I  have  written  this that  your  'notes' 

on  cases  will  not  suffer  any  detrimental  effect  through  my 


656  THE   DIAGNOSIS   OF   SHELL-SHOCK 

imposture. 1  have  not  got  my  discharge  yet,  but  shall 

stick  out  for  it.  I  '  speak  '  but  do  not  '  hear  '  very  well.  — " 
He  was  in  tw^o  hospitals  for  functional  nervous  disorders  in 
England,  but  in  neither  institution  was  he  regarded  as  a 
malingerer. 

Re  hysteria  explained  by  the  patient  as  malingering, 
Chavigny  discusses  what  he  calls  sur simulation.  The  physi- 
cian must  not  fall  into  a  permanent  state  of  suspicion, 
and  especially  must  not  reveal  his  suspicions  to  the  accused 
or  to  the  bystanders.  Chavigny  quotes  a  French  soldier 
whose  letter  to  his  wife  was  intercepted,  stating  that  he  was 
going  to  feign  deafmutism  to  secure  his  discharge.  Before 
he  had  succeeded  in  doing  so,  however,  he  suffered  Shell- 
shock,  and  got  a  true  hysterical  deafmutism,  which  showed 
no  signs  of  malingering  whatever. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  657 


Deaf  mutism :  Appearance  of  malingering. 


Case  464.     (Myers,  September,  1916.) 

A  stretcher  bearer  was  seen  by  Lt.-Col.  Myers  two  days 
after  admission  to  a  base  hospital.  StoHd  looking  and  mute, 
he  had  nevertheless  talked  in  his  sleep,  had  written  a  few 
words  about  "  shells  coming  over,"  and  understood  what  was 
said  to  him.  Lt.-Col.  Myers'  notes  run,  "  He  puts  out  his 
tongue  and  closes  his  eyes  and  holds  out  one  hand  when  I 
ask  him  to  do  so,  but  gets  stupid  (as  if  sulky)  when  I  ask  for 
the  other  hand.  He  will  not  hear  any  more.  Next  day 
quite  deaf,  and  the  following  day  light  anesthesia  with  ether 
caused  a  return  of  hearing  and  of  speech,  with  repetition  of 
syllables  to  request  on  the  way  to  deeper  anesthesia.  On 
awaking  he  cried  as  he  was  induced  to  resume  his  speech,  and 
complained  of  pains  in  the  head. 

"  Two  days  later,  he  seemed  normal  and  said  that  he  could 
have  spoken  on  the  second  day,  but  that  his  eyes  and  ears  had 
begun  to  swim,  that  he  had  felt  dizzy,  and  was  afraid  to  talk. 
He  did  not  want  to  be  sent  back  to  the  trenches.  There  had 
been  severe  shelling.  He  had  lost  consciousness  until  he 
awoke  in  a  hospital  at  Y  — .  He  recalled,  little  by  little, 
how  he  had  been  taken  back  by  a  corporal  to  a  cellar.  He 
said  he  wanted  to  go  back,  but  wanted  a  rest  first.  He  went 
back  to  his  unit  and  was  reported  as  having  done  well  for 
four  months." 

There  was  a  certain  suggestion  of  malingering  about  the 
admission  of  the  lad  that  he  could  have  spoken  before  he 
was  induced  to  do  so.  According  to  Lt.-Col.  Myers,  a  num- 
ber of  patients  upon  recovery  of  speech  are  apt  falsely  to 
believe  that  they  have  been  malingering.  Functional  dis- 
orders may  simulate  malingering. 

Lannois  and  Chavanne  warn  against  the  suggestions  given 
to  malingerers  and  to  hysterics  by  the  statements  on  the 
tickets  of  admission  borne  by  the  patients  for  transfer, 
e.g.  "incurable  deafness."  These  authors  found  11  per  cent 
malingerers  amongst  262  cases  of  labyrinthine  shock. 


658  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Simulation  of  deafmutism. 


Case  465.     (Gradenigo,  March,  1917.) 

A  soldier  in  the  mountain  artillery  acted  like  a  deafmute. 
He  was  unable  to  read  or  write.  It  was  reported  that  he  had 
been  wounded,  but  no  evidence  of  wound  could  be  found. 
The  man  had  a  low  forehead  and  a  furtive  glance,  his  whole 
impression  being  that  of  a  criminal. 

The  only  evidence  of  disease  found  was  inflammation  with 
perforation  of  the  tympanic  membrane  of  the  left  ear.  Deep 
in  the  left  auditory  meatus  was  found  a  grain  of  crushed  oats! 
The  man's  speech  difficulty  was  of  a  stuttering  nature,  but 
he  stuttered  in  a  different  way  at  every  test.  He  was  un- 
willing to  be  narcotized.  Finally  by  a  process  of  scolding  and 
cajoling,  the  man  was  made  to  confess  that  he  could  both 
hear  and  speak  well.  The  peculiar  stuttering  early  led  to 
the  diagnosis  of  simulation,  but  the  fact  that  the  tympanic 
membrane  was  not  anesthetic,  and  that  there  was  no  anes- 
thetic zone  in  the  body  strengthened  the  suspicion  —  to  say 
nothing  of  the  refusal  of  narcosis  and  the  general  behavior  of 
the  somewhat  criminal-looking  soldier. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  659 


A  lame  rascal. 


Case  466.     (GiLLEs,  April,  1917.) 

An  infantryman,  28,  had  an  equinovarus,  for  which  he  was 
evacuated,  hospitalized,  given  treatment,  sent  home  for 
convalescence,  and  declared  unfit  for  service.  He  was, 
however,  sent  back  to  the  front,  and  on  arrival,  went  lame; 
whereupon  the  regimental  surgeon  sent  him  to  a  nerve  center. 
The  equinovarus  was  there  but  it  was  nothing  but  a  simple 
contracture  without  pain,  atrophy,  sensory,  reflex,  electrical, 
or  X-ray  disorders. 

The  abductor  muscles  were  stimulated  by  electricity  and 
the  foot  straightened.  He  was  kept  under  observation  for 
a  time,  was  lame  no  longer,  and  was  sent  back  to  his  regiment. 

However,  sometime  later  he  was  evacuated  again  to  the 
same  neurological  center,  stating  that  he  did  not  know  why. 
There  was  no  longer  any  varus  or  anything  abnormal.  The 
rascal  had  enjoyed  the  game  of  going  lame  and  had  pre- 
vailed upon  his  officers  to  evacuate  him.  He  then  saw  that 
he  was  found  out  and  pretended  that  he  had  been  forcibly 
evacuated. 


66o  THE   DIAGNOSIS   OF   SHELL-SHOCK 


Mother  love  and  jaundice. 


Case  467.  (Briand  and  Haury,  January,  1916.) 
A  soldier,  19^,  entered  tlie  central  psychiatric  service  at 
Val-de-Gr^ce,  having  been  evacuated  from  a  hospital  in 
Paris,  suspect  of  having  brought  about  a  picric  acid  jaundice. 
He  had  been  undergoing  treatment  in  this  hospital,  when 
the  physician  who  had  isolated  him  found  that  he  was  get- 
ting picric  acid  in  packages  secreted  in  his  kepi. 

It  seems  that  the  soldier  lived  with  his  mother,  and  en- 
listed when  he  was  not  yet  18.  He  proved  to  be  as  good  a 
soldier  as  he  was  workman,  and  came  through  the  campaign 
without  wound  or  disease.  Accordingly,  in  December,  191 5, 
he  got  a  six-day  leave.  His  mother,  who  loved  him  well, 
and  of  whom  he  was  the  sole  support,  had  much  regretted  his 
enlisting.  She  was  sick  with  some  stomach  disease  and,  after 
he  enlisted,  she  told  everybody  that  she  was  going  to  die  and 
that  it  was  his  fault.  So,  when  he  came  on  leave  the  next 
day,  she  asked  him  to  take  a  powder  so  he  might  stay  a  fort- 
night. She  did  not  tell  him  the  name  of  the  drug;  only  told 
him  how  to  take  it  in  a  small  paper,  swallowing  it  with  a 
little  water.  She  said  he  would  become  yellow  and  that  he 
would  get  a  supplementary  leave.  Three  days  after  his 
return  to  the  front,  the  boy  took  three  of  the  ten  powders; 
took  the  same  number  three  or  four  days  later;  and  the  others 
five  or  six  days  later.  He  soon  had  jaundice  with  colic  and 
diarrhea,  and  apparently  was  exempted  from  service  for  a 
few  days.  He  had  returned  to  the  front  hardly  a  month 
when  his  mother  died  and  the  boy  got  another  six-day  leave 
for  the  funeral.  He  took  ten  fresh  doses  of  picric  acid  while 
at  Paris,  and  was  put  into  hospital  by  a  physician  without 
suspicion.  His  relatives  thought  he  was  suffering  from  a 
recurrent  jaundice.  When  the  story  was  told,  the  bay  con- 
fessed to  the  family,  and  said  that  he  had  taken  the  drug  in 
the  first  place  only  to  please  his  mother.  It  is  harder  to 
explain  the  second  trial,  since  he  talked  about  the  compassion 
and  sense  of  obedience  he  felt  to  his  dead  mother.  It  is 
probable  that  he  simply  wanted  a  prolonged  leave  at  Paris. 


THE   DIAGNOSIS    OF    SHELL-SHOCK  66 1 

Re  malingering,  Blum  speaks  of  fictitious  jaundice  as  hav- 
ing received  the  name  of  La  Carotte  (the  carrot)  from  the 
soldiers.  Blum  gives  a  partial  list  of  instances  of  simula- 
tion as  follows: 

SIMULATION 
(Blum,  December,   1916) 

False  a7igma,  from  irritating  solution. 

Gastric  disorder.  Oil  and  tobacco  (with  tachycardia  or 
jaundice)  (use  ipecac). 

Diarrhea.      (Isolate.) 

Diarrheal  stools  imitated  by  a  mixture  of  urine  and 
water. 

Dysenteric  stools  imitated  by  the  addition  of  fat  pork  and 
bits  of  raw  meat. 

Appejidicitis.  Complaint  of  pain  at  the  well-known  Mc- 
Burney  point. 

Tape  worm.     Carriers  supply  others. 

Jaundice.  (Smoke  mixture  of  antipyrin  and  tobacco; 
drink  tobacco  juice.     Ingest  picric  acid.) 

Hemoptysis.     Irritation  of  throat  surfaces  with  a  needle. 

Albuminuria.  Eat  kitchen  salt  to  excess  in  a  bowl  of 
milk.  Edema  and  albumin  disappear  on  surveillance.  Al- 
bumin injected  into  bladder. 

Diabetes.  Phloridzin,  or  oxalate  of  ammonia.  Glucose 
added  to  urine. 

Incontinence.  (Difficult  to  prove  fraudulent.  True  in- 
continence in  middle  of  night.  Simulated,  just  before  wak- 
ing.) 

Skin  diseases: 

Erythema.     Herbs. 

Eruptions.     Mercury,  arsenic,  iodine,  bromide. 
Herpes.     Euphorbiacae. 

Eczema.  Rubbing  with  slightly  warmed  thapsia.  Rub- 
bing excoriated  skin  with  acids,  Croton  oil,  bark  of  garou, 
sulphur,  oil  of  cade,  mercurial  pomade. 


662  THE  DIAGNOSIS   OF   SHELL-SHOCK 

Impetigo.     With  cantharides  plaster  and  pomade  stibiee. 

Intertrigo.     (In  the  infantry.) 

Hyperidrosis  of  feet.  Prolonged  hot  baths.  Hot  foot 
baths  with  excoriation,  followed  by  scratching  and  covering 
with  linen  soaked  in  urine. 

Edema  of  legs.     Constriction. 

(In  Lombardy,  cases  due  to  introduction  of  equisetum 
arvense,  an  astringent  herb,  by  fingers  and  toes,  followed  by 
energetic  rubbing.) 

Recurrent  wounds.     (Cover  with  wax  sealed  bandages.) 

Abscesses.  Introduction  of  septic  material.  A  thread 
soiled  with  tartar  from  teeth  is  drawn  through  the  skin. 
Characteristic  odor  of  resulting  abscess. 

Phlegmons.  Subcutaneous  introduction  of  turpentine  or 
petrol. 

Paraffine  tumors.     (Apply  heat.) 

Sprain.  A  stopper  is  put  under  the  heel ;  or  compress  the 
leg  with  bandages  to  stop  circulation  and  knock  below  re- 
peatedly and  forcibly.     Edema  and  ecchymosis  follow. 

Conjunctivitis.  Ipecac,  pepper,  septic  or  fecal  materials. 
Pupillary  dilatation  has  been  produced  by  introduction  of  a 
belladonna  grain  under  the  eyelid  daily. 

Ears.  Running  at  the  ears  produced  by  placing  urine  or 
chemical  product  in  the  ear. 

Emaciation  and  pallor.  Ingestion  of  a  large  amount  of 
vinegar.     Abuse  of  strong  tobacco. 

Muscular  weakness.  Arsenious  acid  in  eggs.  Voluntary 
lead  and  mercurial  intoxications. 

Epilepsy.  Absence  of  pupillary  reflex  to  light  and  pupil- 
lary dilatation,  insensibility  of  nasal  mucosa  and  modifica- 
tions of  pulse  persistent  after  the  attack  is  over  cannot  be 
imitated. 

Fever.  Striking  elbows  against  walls  to  elevate  the  mer- 
cury In  the  thermometer.     Take  temperature  by  rectum. 

Bites.  One  simulator  had  a  fork  with  twisted  teeth  to 
produce  the  effect. 

Intra-abdominal  projectiles.     Bullet  swallowed. 


THE   DIAGNOSIS   OF   SHELL-SHOCK  663 


Swelling  of  hand  and  forearm,  seven  months. 


Case  468.     (Leri  and  Roger,  September,  191 5.) 

A  soldier  was  wounded  September  22,  1914,  at  Charleroi 
by  a  bullet  In  the  forearm.  He  came  under  observation 
May  14,  191 5,  with  a  huge  edema  of  forearm  and  hand, 
suddenly  stopping  at  the  elbow,  an  elastic  edema,  especially 
marked  in  the  palm,  which  was  restored  to  its  smooth  contour 
very  quickly  after  being  compressed  by  the  fingers,  and  very 
like  an  elephantiasis.  The  hand  was  in  a  position  of  moderate 
extension  on  the  forearm,  with  fist  clenched.  There  was  a 
linear  ecchymotic  line  at  the  upper  edge  of  the  zone  of  edema, 
especially  on  the  antero-internal  face. 

According  to  the  soldier's  own  story,  the  swelling  had  be- 
gun a  fortnight  after  the  injury.  He  said  that  a  very  tight 
moist  dressing  had  been  applied  during  the  first  few  days. 

The  patient  was  cared  for  by  massage,  and  then  by  local 
baths.  He  was  anesthetized  In  December  and  several  drains 
were  inserted;  no  result.  In  January  he  was  chloroformed 
again  and  two  long  incisions  were  made  along  the  Internal 
border  of  the  supinator  longus  and  along  the  ulnar  border  of 
the  forearm.  He  was  better  for  two  weeks  after  this  second 
operation,  but  then  grew  worse. 

The  diagnosis  of  syringomyelia  was  now  made,  based  upon 
the  appearance  of  the  arm  and  upon  some  ill-defined  hypes- 
thesia.  This  diagnosis  was  not  entertained  by  Leri  and 
Roger  who,  when  they  obtained  the  patient,  put  him  into  a 
plaster  cast  up  to  the  shoulder.  The  edema  went  down 
rapidly  to  normal.  In  short,  it  was  here  a  question  of  a 
simulator,  who  was  even  willing  to  undergo  surgical  operations 
with  general  anesthesia. 

Re  evading  service,  Gleboff's  classification  is  as  follows: 
I.  False  assertion  of  disease  of  {a)  Internal  organs,  {b)  vis- 
ion, (c)  hearing,  (d)  joints.  2.  Simulation  of  temporary 
disease  of  organs.     3.    Mutilation  of  limbs. 

Re  swelling  of  hand  and  forearm,  see  remarks  on  hysterical 
edema  under  Cases  407  and  456. 


664  THE  DIAGNOSIS   OF   SHELL-SHOCK 


A  German  shell-shy. 


Case  469.     (Gaupp,  April,  1915.) 

Gaupp's  simulator  had  not  been  under  shell  fire.  He  said 
to  his  captain  that  he  wanted  to  see  his  badly  wounded 
brother  (he  had  in  fact  no  brother),  and  got  a  furlough  on 
this  ground.  He  then  fled  as  far  as  possible  from  the  front, 
into  the  interior,  roved  about  for  some  days,  falsely  asserting 
that  he  was  under  dentist's  treatment. 

He  was  brought  to  Tubingen  on  the  ground  of  mental 
derangement,  on  a  hospital  train,  and  was  delivered  to  the 
clinic  as  a  case  of  Shell-shock.  This  man's  state  of  excite- 
ment soon  ended.  As  Gaupp  could  not  make  out  his  case 
clinically,  he  applied  to  the  regiment  and  received  in  return 
court-martial  papers.  The  man  confessed  that  he  had  made 
false  statements  and  fled  because  he  was  afraid  of  shells. 
Reproached  with  simulation,  he  preserved  a  shameful  silence. 


A  fair  exchange  no  robbery :  France  gets  a  simu- 
lator in  an  exchange  with  Germany  of  prisoners 
"  unfit  for  service." 


Case  470.     (Marie,  April,  1915.) 

A  French  soldier  arrived  in  France  from  Germany  in  a 
reciprocal  exchange  of  prisoners  supposed  to  be  incapable^© f 
bearing  arms.  The  man  showed  a  paraplegia  with  clonic 
movements  of  exaggerated  degree.  He  was  rapidly  "  cured  " 
after  being  placed  in  a  military  hospital,  and  disciplined. 
He  proved  to  be  a  vulgar  simulator. 

It  was  clear  that  the  German  physicians  had  made  a  gross 
error  in  diagnosis;  but  what,  asks  Marie,  should  be, done 
with  such  a  man,  since  he  evidently  should  not  be  given  a 
convalescent  leave  or  a  retirement?  Should  he  be  sent  back 
to  his  depot? 

If  a  year's  treatment  yields  no  results,  Grasset  suggests 
discharge  with  suitable  gratuity. 


THE  DIAGNOSIS   OF   SHELL-SHOCK  665 


SIMULATION :  Question  of  Quincke's  disease. 


Case  471.     (Lewitus,  May,  1915.) 

An  infantryman  was  brought  to  the  eye  department  of 
the  Wieden  Hospital  early  in  May,  1915,  with  a  diagnosis 
(from  the  internists)  of  Quincke's  disease. 

Under  the  conjunctiva  of  each  globus  oculi  were  count- 
less small  air  vesicles.  There  was  not  the  slightest  em- 
physema of  the  eyelids  or  of  the  skin  about  the  eyes.  The 
skin  in  the  neighborhood  of  the  zygoma  was  thick,  red  and 
swollen;  but  no  air  could  be  demonstrated  in  the  subcutane- 
ous tissues  on  palpation.  Next  day  the  skin  swelling  and 
the  conjunctival  emphysema  had  disappeared.  No  com- 
munication of  the  orbits  with  the  air  spaces  of  the  skull 
could  be  demonstrated  nor  was  it  possible  to  push  air  into 
the  conjunctiva  by  nose-blowing.  The  fundi  were  both 
normal  and  vision  was  normal.  Special  rhinological  examina- 
tion showed  the  nose  to  be  normal.  It  was  the  skin  swelling 
of  the  orbital  region  that  had  given  rise  to  the  diagnosis  of 
Quincke's  disease.  The  man  had  been  then  referred  to  the 
internists  who  could,  however,  find  no  evidence  of  disease 
whatever. 

During  the  three  months'  stay  of  the  patient  in  the  eye 
department,  once  more  swelling  of  the  left  orbital  region 
and  air  under  the  conjunctiva  of  the  left  globus  oculi  suddenly 
appeared  one  day,  but  disappeared  over  night.  At  this  time 
small  subconjunctival  ecchymoses  were  found. 

This  case  must  be  regarded  as  one  of  simulation  but  pro- 
duced in  a  manner  unknown. 


666  THE  DIAGNOSIS   OF   SHELL-SHOCK 


Bruises  of  head  and  back,  not  severe:  "A  case 
of  pensionitis,  a  self-made  neurasthenic  for  medi- 
colegal purposes." 


Case  472.     (Collie,  May,  1915-) 

Sir  John  Collie  remarks  that  sometimes  one  has  to  recom- 
mend a  pension  knowing  that  what  amounts  to  a  fraud  is 
being  perpetrated.  A  seaman,  25,  got  newspaper  notoriety 
after  receiving  ^'some  not  very  serious  bruises  of  head  and 
back.  Two  months  later,  when  seen  by  Sir  John  Collie, 
he  was  a  victim  of  bent  back.  He  was  finally  able  to  remove 
his  clothes  and  put  them  on  with  some  alacrity,  although  at 
first  he  declared  he  could  not.  Woebegone  during  exami- 
nation, he  was  noted  to  laugh  and  gossip  with  strangers  out- 
side. A  physician  had  diagnosticated  it  as  an  obscure  spinal 
lesion,  but  as  he  was  fit  to  work,  he  was  sent  back. 

Forty-one  days  later  he  put  himself  on  the  sick-list  again. 
Pluck  and  nerve  were  gone  beyond  recall,  according  to  his 
physician.  In  hospital  his  appetite  was  good,  he  slept  well, 
and  he  had  no  troubles  except  an  hysterical  loss  of  sensation. 
There  followed  33  days  in  hospital,  three  weeks  in  a  convales- 
cent home,  and  return  to  work  for  a  month.  Unable  to 
stoop  or  kneel  for  pain,  he  was  thought  organic. 

Sir  John  found  him  without  desire  to  get  well,  hysterical, 
and  suffering  "  from  pensionitis,  a  self-made  neurasthenic  for 
medico-legal  purposes."  He  was  placed  for  four  months  in  a 
nerve  hospital.  On  leaving  this  hospital  he  was  still  in  the 
bent-back  position,  and  went  into  a  pantomime  display  when 
asked  to  touch  his  toes.  Four  weeks  in  the  convalescent 
home  found  the  following:  The  attending  physician  now 
suggested  locomotor  ataxia  as  the  correct  diagnosis!  Sir 
John  Collie  was  asked  to  report  finally  as  to  the  fitness  for 
work.  Well  assured  that  the  patient  was  really  a  malingerer, 
Sir  John  nevertheless  certified  him  as  permanently  unfit  for 
further  service  as  a  case  of  traumatic  neurasthenia,  venturing 
to  predict  that  after  receiving  the  pension,  he  would  be  at 
work  within  six  months.     He  received  the  pension  (25  s.  a 


THE  DIAGNOSIS  OF   SHELL-SHOCK  667 

week  for  life),  and  Sir  John  Collie's  ability  at  prediction  was 
justified  by  his  return  to  work,  at  the  end  of  exactly  six  months. 
Re  malingerers,  Glueck  remarks  that  a  malingerer,  besides 
being  a  malingerer,  is  a  worthless  sort  of  person  in  any 
event,  and  calls  attention  to  the  fact  that  special  stresses 
may  reduce  men  to  lower  cultural  levels,  to  which  lying  and 
deceit  may  be  more  appropriate.  Glueck  remarks  that  the 
lay  mind  does  not  readily  appreciate  that  a  man  with  mental 
disease  may  at  the  same  time  be  a  malingerer  of  additional 
mental  symptoms.  It  may  be  added  that  the  professional 
mind  is  sometimes  equally  slow  to  appreciate  the  fact. 


668  THE  DIAGNOSIS   OF   SHELL-SHOCK 


SHELL-SHOCK 

GROUP   I.   EXHAUSTION 

(Alcoholism  perturbs  treatment) 

GROUP   II.   HEREDITY 

(Certain  poor  recruits) 

GROUP   III.    MARTIAL   MISFITS 

(Wrong  attitude  of  mind) 

After  Farquhar  Buzzard 


Chart  14 


THE   DIAGNOSIS   OF   SHELL-SHOCK  669 


NEUROSES  AND  PSYCHOSES  OF  WAR 

1.  NEUROSES 

Motor 
Sensory 

2.  NEUROSES 

Special  Sensory 
Speech 

3.  NEURASTHENIA 

Hemichorea 
Exophthalmic  Goitre 
Trench  Spine 

4.  PSYCHOSES 

Minor 
Gun-shy,     Insomnia,    Dreams,     Phobias,     Psychasthenia, 
Hypochondria 
Stupor,  Anergia,  Acute  Dementla. 
Psychoses  (Civilian  Forms) 

After  A.  W.  Campbell 


Chart  15 


'E  pero  leva  su,  vinci  I'ambascia 

con  I'animo  che  vince  ogni  battaglia 
se  col  suo  grave  corpo  non  s'accascia. 

'Piu  lunga  scala  convien  che  si  saglia: 
non  basta  da  costoro  esser  partito 
se  tu  m'intendi,  or  fa  si  che  ti  vaglia. " 

'And  therefore  rise!  conquer  thy  panting 
with  the  soul,  that  conquers  every  battle, 
if  with  its  heavy  body  it  sinks  not  down. 

'A  longer  ladder  must  be  climbed : 
to  have  quitted  these  is  not  enough; 
if  thou  understandest  me,  now  act  so  that  it 
may  profit  thee." 

Inferno,  Canto  xxiv,  52-57. 


670 


D.     TREATMENT  AND  RESULTS  OF 
SHELL-SHOCK. 

In  previous  sections  we  have  already  become  acquainted 
with  many  therapeutic  successes  and  failures :  indeed  it  was 
almost  necessary  to  detail  treatment  in  certain  cases  to  show 
the  nature  of  the  disease  in  hand  or  the  correctness  of  a  given 
diagnosis.  In  the  present  Section  we  approach  the  question 
more  systematically. 

After  presenting  a  few  examples  of  various  spontaneous  and 
non-medical  recoveries,  we  bring  into  contrast  the  types  of 
medical  recovery  that  may  be  termed  rapid  (or  miracle) 
cures  and  those  that  fall  under  the  general  head  of  reedu- 
cation. Admixed  are  cases  of  failure  as  well  as  of  success: 
if  it  be  remarked  that  the  case  method  puts  forward  the 
best  foot,  it  is  probable  that  the  same  is  true  of  almost  any 
therapeutics  as  reported  in  early  articles.  As  we  go  to  press, 
trench  reports  indicate  that  at  least  one  part  of  the  profes- 
sion is  far  more  hopeful  of  successful  psychotherapy  even  in 
the  physiopathic  group  of  disorders  than  their  expounder, 
Babinski,  could  concede.  The  true  statistical  evaluation  of 
the  results  must  come  years  later. 

Some  neuropsychiatrlsts  have  been  fond  of  saying  that 
there  is  nothing  nev/  in  Shell-shock,  that  specialists  have  long 
been  familiar  with  the  psychoneuroses,  etc.  Yet  in  the 
past,  specialists  have  not  learned  overmuch  about  the  true 
inwardness  of  the  psychoneuroses.  Even  a  casual  inspection 
of  the  various  therapeutic  efforts  here  described  shows  how 
much  novelty  of  observation  and  ingenuity  of  plan  must 
eternally  be  shown  in  these  ever-so-simple  psychoneuroses! 


671 


672  TREATMENT  AND  RESULTS 


Shell-shock :  Deaf  mutism.     Spontaneous  cure. 


Case  473.     (MoTT,  January,  1916.) 

A  British  soldier,  25,  a  coal  miner,  had  had  a  bicycle 
accident  five  years  before,  after  which  he  was  unconscious  for 
2|  hours,  and  gave  up  work  for  five  weeks,  with  headaches, 
fainting-fits,  and  nervousness  ever  after  and  with  a  tend- 
ency to  imagine  he  could  see  things  when  there  was  nothing 
to  be  seen. 

September  19,  1915,  he  was  under  shell  fire  in  trench  and 
dugout.  A  sergeant  and  three  men  working  with  him  were 
killed  by  an  explosion,  and  he  remembers  his  cap  being  lifted 
off  his  head.  He  came  to  in  46  Rest  Camp,  some  time  later, 
unable  to  see  clearly,  or  to  hear  or  speak,  and  with  headache 
and  insomnia.  He  brought  a  paper  from  a  hospital  in 
France,  saying,  "  Doctor,  I  had  an  awful  dream  last  night 
again ;  I  was  dreaming  that  I  was  in  the  trenches ;  I  could  see 
the  men  falling  and  the  great  big  shells  exploding.  I  could 
see  the  light  from  the  bursting  of  the  shells  very  plain.  They 
fairly  lighted  all  the  place  up.  I  woke  up  very  anxious  I  can 
tell  you.  I  wish  I  could  give  over  dreaming,  and  I  keep 
having  pains  in  my  head  right  across  my  eyes." 

October  15,  while  sitting  by  himself  outdoors,  he  felt  a 
slight  crackling  in  his  head,  noticed  that  he  could  hear  sounds 
faintly,  and  in  a  few  minutes  he  could  hear  fairly  well. 

October  17,  he  was  heard  making  inarticulate  noises  in  his 
sleep.  The  corporal  next  him  told  him  about  the  noises  in 
his  half  drowsy  state;  he  tried  to  speak  and  said,  "  Mother." 
He  then  felt  queer  all  over,  with  pain  in  his  head,  and  after- 
ward became  able  to  talk  very  well  with  slight  hesitation. 

Re  spontaneous  cures,  Elliot  Smith  and  Pear  cite  the 
cure  of  two  mutes  on  hearing  that  Roumania  had  entered 
the  war,  and  the  cure  of  another  by  seeing  Charlie  Chaplin's 
antics.  Some  workers  (for  example,  Aime),  treat  the  func- 
tional mutes  by  simply  leaving  them  to  themselves,  and 
maintain  that  they  secure  numerous  spontaneous  recoveries, 
regarding  these  as  superior  to  cures  by  isolation,  psycho- 
therapeutic treatmentj-^and  the  like. 


TREATMENT  AND  RESULTS  673 


METHODS   OF  PSYCHOTHERAPY 


HYPNOSIS 
Verbal  Suggestion 
Fixation 
Fascination 
Various 

SUGGESTION    (WAKING) 
Verbal 
Drug 
Apparatus 

AUTOSUGGESTION 

DISTINCTION 

TERRORISM 

INFLICTION   OF   PAIN 

PERSUASION 

WILL  TRAINING 

OCCUPATION  THERAPY 

ISOLATION 

PSYCHOANALYSIS 


Chart  16 


674  THE   DIAGNOSIS    OF    SHELL-SHOCK 

Re  mutism  spontaneously  or  non-medically  cured,  see  also 
cases  476,  480,  481,  482.  For  various  medical  methods  of 
treatment,  see,  e.g.,  cases  516,  518,  520,  526,  544,  579. 

Mott  had  a  case  which  had  been  mute  more  than  six 
months,  unable  to  whistle,  phonate  in  coughing,  or  blow 
out  a  candle,  though  heard  to  shout  in  his  sleep:  This 
patient  recovered  his  speech  when  pitched  out  of  a  punt  on 
New  Year's  Eve.  The  condition  was  in  one  sense  physical 
enough,  as  the  X-ray  showed  that  the  man's  diaphragm 
hardly  moved  even  with  the  greatest  effort.  Mott  regarded 
the  inhibition  of  the  breathing  movements,  especially  the 
phonation,  as  caused  by  fear.  Mott  speaks  of  a  case  that 
recovered  on  being  told  by  a  comrade  that  he  had  talked  in 
his  sleep.  The  man  was  so  astonished  by  this  statement 
that  he  said,  "I  don't  believe  it."  Other  instances  of  cure 
under  quasi  natural  conditions  are  related  by  Mott:  In  the 
presence  of  a  functional  mute,  Mott  speaks  loudly  to  the 
patient's  sister  so  that  the  patient  may  hear:  "This  man 
must  be  kept  on  a  No.  i  diet,  and  when  he  can  ask  loud 
enough  for  you  to  hear,  he  can  have  a  bottle  of  stout  and  a 
mutton-chop."  Several  mutes  are  reported  to  have  gotten 
well  the  next  day  under  this  treatment. 

These  effects  shade  imperceptibly  over  into  the  mani- 
festly suggestive,  and  probably  no  sharp  line  can  be  drawn 
between  the  effects  of  medical  suggestion,  non-medical  hetero- 
suggestion,  and  even  autosuggestion.  Adrian  and  Yealland 
rather  decry  the  Micawber  line  of  waiting  for  something  to 
turn  up.  Zeehandelaar,  a  Dutch  professor,  studied  Berlin 
methods  (Lewandowsky) ,  and  found  numerous  cases  (both 
of  mutism  and  of  deafness,  paralyses,  contractures,  and 
tremors)  lying  about  without  special  treatment.  According 
to  this  observer,  the  expectant  treatment  was  sometimes 
successful,  and  sometimes  not;  if  unsuccessful,  the  soldier 
was  sent  home,  and  re-examined  a  year  later;  whereupon 
he  might  be  found  to  have  profited  by  this  long  waiting  and 
to  have  gotten  well  enough  to  return  to  army  duty. 


TREATMENT  AND  RESULTS  6/5 


A  decorated  officer,  evacuated  for  Shell-shock  on 
the  third  day  of  the  Aisne,  after  four  days  returns  to 
the  front.  Evacuated  a  second  time,  after  weeks 
returns  to  the  front  without  relapse. 


Case  474.     (GiLLES,  191 6.) 

A  young  officer,  with  many  decorations  for  brilliant  Colo- 
nial service,  was  in  the  battle  of  the  Marne,  under  six  con- 
secutive days'  shell  fire,  smoked  phlegmatically  a  cigarette 
no  matter  whether  walls  were  crashing  or  horses  disembow- 
eled beside  him,  and  was  uniformly  able  to  stimulate  his 
men  to  the  heavy  work  by  humor  or  heroic  phrases. 

A  week  later,  on  the  third  day  of  the  Aisne,  he  had  to  be 
evacuated.  He  was  another  man  —  wild-eyed,  shivering, 
jumping  at  the  least  noise,  unable  to  eat  or  sleep,  given  to 
battle  dreams.  He  had  to  be  carried  away  from  the  battle 
zone  and  put  in  a  bed  in  a  town  in  the  rear  and  given  chloral. 
The  nightmares  continued.  On  being  awakened  he  would 
ask  where  he  was.  He  was  kept  in  bed,  given  strychnine 
cacodylate,  and  dieted.  He  went  back  to  the  front  in  four 
days.  Two  days  later  he  had  to  be  evacuated  a  second  time. 
After  some  weeks  more  in  the  rear,  however,  he  went  back  to 
the  front,  and  thereafter  had  not  relapsed  (April,  1916.) 

Re  relapses,  Wiltshire  thinks  their  causes  and  frequency 
prove  the  psychogenic  nature  of  Shell-shock.  Ballard  states 
that  a  severe  case  lasting  six  months  does  not  recover  in  the 
army.  Many  that  are  said  to  recover  in  hospital  break  down 
at  depots,  often  with  symptoms  quite  unlike  those  which  they 
originally  presented,  and  it  will  be  remembered  that  Ballard 
has  an  epileptic  theory  of  the  nature  of  Shell-shock.  See 
Cases  82,  83,  and  84  in  Section  A,  HI,  Epileptoses.  But 
another  portion  of  Ballard's  contentions  relates  to  a  causa- 
tion through  fear  suppressions  released  by  perturbing  events. 
According  to  Ballard,  if  the  man  endeavors  to  re-suppress 
the  released  fear,  the  fits  occur.  Ballet  and  DeFursac  note 
the  frequency  of  relapses  —  fewer  after  treatment  at  the 
front. 


676  TREATMENT  AND   RESULTS 


Vicissitudes  in  fifteen  months  of  a  Shell-shock  case 
with  mutism  and  amnesia.  Attacks  of  mania. 
Hyperthyroidism? 


Case  475.     (Purser,  October,  191 7.) 

An  Englishman,  21,  in  a  rifle  regiment,  arrived  in  May, 
1915,  at  the  Dublin  University  V.  A.  D.  Hospital,  being 
dumb,  impaired  as  to  vision  and  hearing,  having  dilated 
pupils,  tremors,  restlessness  and  weakness,  and  giving  the 
impression  of  visual  hallucinations.  Although  suspicious, 
he  was  treated  kindly  for  a  few  days,  recovered  his  hearing, 
and  wrote  the  few  things  that  he  remembered  about  home 
and  the  war,  now  and  then  tremulously  and  perspirlngly 
writing  down,  "  Asylum;    do  not  lock  up;    I  am  not  mad." 

With  the  Idea  of  hypnosis,  his  bed  was  surrounded  by 
screens,  whereupon  he  grew  so  perturbed  that  the  attempted 
hypnosis  could  not  be  executed.  He  learned  the  letters 
PP,  TT,  SSS,  A-000,  and  finally  AA-SS,  AA-TT,  T-00, 
and  after  many  weeks  SS-SST-R  and  B-TT-R.  His  father 
visited  him  and  probably  was  recognized. 

At  the  end  of  September  another  dumb  Shell-shock  case 
recovered  speech  upon  being  given  ether.  Maj.  Purser  asked 
the  sister  to  arrange  for  a  like  treatment  for  the  first  case, 
explaining  that  an  examination  of  his  throat  might  be  pain- 
ful. The  cure  of  the  second  case  by  anesthesia  got  Into  the 
papers  and  before  he  was  treated  the  account  was  possibly 
seen  by  the  hitherto  gentle  rifleman.  At  any  rate,  he  was 
seized  with  a  sort  of  spasm,  became  furious  and  could  only 
see  Germans  coming  and  carrying  off  his  machine  gun.  He 
shouted  for  help.  A  half  grain  of  morphine  was  given  him 
and  when  it  began  to  take  effect  the  fighting  spirit  gave  way 
to  despair.  He  trembled  over  the  loss  of  the  gun,  and  re- 
mained in  this  state  of  despair  for  three  days,  remembering 
his  regiment  number  and  the  like,  but  amnestic  for  his  life 
during  the  past  few  months.  He  could  not  read  now  be- 
cause print  was  indistinct.  Words,  when  he  had  spelled 
them  out,  conveyed  no  meaning.     He  had  a  functional  alexia. 


TREATMENT  AND  RESULTS  677 

When  he  saw  a  picture  of  a  bunch  of  flowers  in  a  notebook  of 
his,  he  had  another  spell  of  excitement  and  regained  his  power 
of  speech,  remembering  about  his  experiences  only  that  he 
had  been  locked  up.  He  had  now  completely  forgotten  his 
father,  who  came  to  call. 

By  the  end  of  October  he  was  stronger,  but  his  horizon  was 
still  limited  to  the  hospital  surroundings  and  a  little  news- 
paper reading.  Headaches  and  impaired  vision  persisted. 
Sight  temporarily  left  him  early  in  November,  and  there  was 
a  suggestion  of  an  epileptic  fit  one  day  early  in  that  month. 
Tonic  and  sedative  drugs  and  suggestive  remedies  were  of 
no  avail.  Hypnotism  made  him  worse,  and  psychanalysis 
was,  perforce,  ineffective  through  the  amnesia.  At  the  end 
of  November  depression  and  suicidal  thoughts  set  in,  with 
an  elevation  of  blood  pressure  to  178  m.m.,  pulse  80  to  90. 
J\Iaj.  Dawson  then  thought  he  was  a  suicidal  melancholic. 
Rest  in  bed  and  thyroid  extract  were  given,  but  the  latter 
threw  up  his  pulse  on  the  fifth  day  to  140.  He  grew  better 
mentally  on  the  treatment,  however,  and  his  blood  pressure 
fell  to  140  in  three  weeks.  He  was  now  over-emotional, 
unable  to  stand  or  walk  or  feed  himself  or  to  pull  on  his  socks. 

For  change  of  scene  he  was  transferred  to  Mercer's  Hos- 
pital in  February,  1916.  He  suffered  from  astasia- abasia. 
The  tremor  became  jerky,  coarse  and  persistent.  The  thy- 
roid gland  grew  a  good  deal  in  size  during  the  spring  and  the 
pulse  went  up  to  120  per  minute.  There  was  also  well-marked 
dermographia  and  there  was  a  suggestion  of  the  clinical 
picture  of  Graves'  disease.  Even  a  quarter  grain  of  morphine 
had  little  or  no  effect  upon  an  ineradicable  insomnia. 

Maj.  Purser  gave  the  case  up  as  a  bad  job  and  the  man  was 
discharged  and  sent  home  September  2,  19 16.  During  the 
next  two  months  at  home  he  improved  in  steadiness,  though 
he  flushed  if  dealing  with  strangers,  and  improved  as  to  mem- 
ory. He  began  to  be  able  to  read  better.  He  had  begun  to 
be  able  to  get  about  on  his  feet  without  so  much  support. 
The  ultimate  outcome  could  not  be  reported  by  Maj.  Purser. 


678  TREATMENT  AND  RESULTS 


Shell-shock :  Mutism.     Cure  after  killing  a  snake. 


Case  476.     (Jones,  1915.) 

An  Australian  soldier  of  20  went  to  Egypt,  thence  to  Gal- 
lipoli  where,  on  July  29,  1915,  he  was  almost  completely  buried 
by  earth  from  the  bursting  of  a  high  explosive  shell.  He 
was  admitted  to  hospital  August  5  and  transferred  to  Malta, 
where  he  did  not  speak,  stared  into  space  and  sometimes 
made,  impulsively,  attempts  to  get  away.  About  September 
17  he  began  to  assist  the  orderlies  and  played  draughts. 

The  diagnosis  there  was  cerebral  concussion.  He  was  sent 
back  to  Australia  by  transport  and  had  to  be  put  in  a  padded 
cell  on  November  i ,  having  become  violent,  noisy:and  destruc- 
tive. He  would  assault  anyone  who  beat  him  at  the  game  of 
draughts  and  threw  anything  he  could  lay  his  hands  on  out 
of  the  porthole.  Hyoscine  he  resented  and  threatened  the 
givers  by  signs.  He  was  at  times  restrained.  He  threat- 
ened to  throw  himself  overboard.     Diagnosis:  Melancholia. 

At  Melbourne  he  was  found  in  good  physical  shape,  but 
dazed,  mute,  apparently  deaf,  indicating  his  wants  by  signs. 
With  pencil  and  paper  he  would  draw  a  ship  or  a  gun  and 
would  copy  any  question  put  to  him  in  writing.  He  played 
draughts  intelligently  and  made  friends  with  one  of  his  ship- 
mates. In  four  days'  time  he  began  to  communicate  in  writ- 
ing, answering  simple  questions  correctly.  Asked  to  put  a 
question,  he  wrote  "  Do  you  think  I  am  mad?"  On  the  ap- 
propriate answer  he  shook  hands  with  the  physician  heartily. 

He  was  then  sent  to  a  military  convalescent  home  at 
HIghton.  Here  he  communicated  often  in  writing,  and  had 
an  appreciation  of  sounds  without  distinguishing  words. 
At  a  picnic  on  December  4  he  killed  a  snake.  While  return- 
ing in  the  dark  he  began  to  whistle  a  song  the  rest  of  the 
party  were  singing.  At  the  end  of  the  song  he  clapped  his 
hands  and  said,  "  What  is  the  next  Item  on  the  program?" 
Thereafter  he  was  able  to  hear  and  speak.  Seen  four  days 
later  he  asked  to  join  the  officers'  training  school.  However, 
he  was  discharged  as  permanently  unfit  for  the  service. 


TREATMENT  AND  RESULTS  679 


Course  in  hospital  of  an  oniric  delirium. 


Case  477.  (BuscAiNO  and  Coppola,  January,  191 6.) 
An  Italian  gun-maker,  27  (father  neurotic;  grandmother 
and  mother,  alcoholic;  patient  excessive  onanist),  was  called 
to  arms  June  14,  191 5,  and  went  into  artillery  service  in  the 
Tolmino,  early  in  September.  Some  time  later,  a  shell  burst 
about  30  meters  away  and  killed  his  lieutenant.  The  pa- 
tient, however,  was  not  hurt  and  did  not  even  fall.  He  be- 
came mute  and  inaccessible,  and  was  sent  to  a  military 
hospital,  and  thence  to  an  asylum  in  Udine,  where  he  was 
restless  and  hallucinatory.  October  2,  he  was  sent  to  Flor- 
ence on  two  months'  leave  for  convalescence.  He  was  still 
hallucinated,  always  seeing  his  dead  lieutenant.  He  spoke 
rarely,  slept  little,  and  his  conduct  became  more  and  more 
queer.  Now  and  again,  he  would  act  exactly  as  if  he  were  at 
the  front.  November  5,  he  started  off  to  find  his  brother, 
but  was  met  by  a  hospital  attendant,  who  promptly  took 
him  to  a  clinic.  Here  he  was  inaccessible  and  lived  in  a 
hallucinatory  way  a  soldier's  life  at  the  front:  in  continual 
movement,  shielding  his  eyes  with  his  hands  as  if  looking  far 
into  the  distance,  bending  down  to  turn  an  imaginary  lever, 
apparently  taking  part  of  his  aim,  crouching  in  a  corner, 
clapping  his  ears  with  his  palms,  and  obeying  hallucinatory 
commands:  "Ready,"  "Fire,"  and  the  like.  As  to  his  in- 
terpretation of  the  actual  surroundings,  he  would  give  a 
military  salute  at  the  entrance  of  the  physician,  as  if  he  were 
the  lieutenant.  Another  patient  near  by  was  interpreted  as 
a  spy.  Hypodermic  Injections,  November  6,  were  Inter- 
preted as  military  antityphoid  injections.  On  succeeding 
days  he  piled  dry  horse-chestnut  leaves  for  a  parapet,  which 
became  the  scene  of  battle.  November  12  he  had  become  a 
little  more  lucid.  November  14,  he  evidently  heard  whist- 
ling and  made  the  leaves  ready  as  a  bed  for  horses.  Novem- 
ber 15,  he  rolled  up  his  blanket  In  a  military  fashion  and  hid 
in  a  cell  corner.  He  explained,  November  16,  that  he  was  a 
sentinel  and  had  not  been  relieved  by  the  corporal.  He  had 
saved  everybody's  lives  by  signaling  from  a  tree  the  presence 


680  TREATMENT  AND  RESULTS 

of  four  airplanes.  He  could  not  be  convinced  he  was  in  an 
institution  for  the  insane.  November  20,  he  was  virtually 
recovered  but  amnestic  for  what  he  had  done  since  commit- 
ment. Headaches  and  dizziness.  November  21,  he  remem- 
bered some  of  his  dreams,  especially  one  of  being  blinded 
and  another  of  being  tied  by  a  German  to  a  tree.  By  No- 
vember 29  he  had  become  lucid  and  oriented,  but  there  was 
an  amnestic  gap  for  his  stay  at  the  clinic.  Early  in  December 
the  fields  of  vision  were  contracted;  polyopia  and  a  glaring 
and  burning  sensation  before  the  eyes  (after  each  test  con- 
junctival and  tear  duct  inflammation). 

December  21,  discharged  well. 

Re  the  nature  of  oniric  delirium,  see  discussion  under 
Cases  333  and  450,  Chavigny  had  but  two  cases  out  of  260 
in  which  a  rapid  curability  was  noted  (90  per  cent  finally 
curable).  Chavigny's  treatment  consists  of  rest  in  bed, 
quiet,  purgation  if  necessary,  and  warm  or  cold  shower 
baths.  Chavigny  remarks  upon  the  extraordinary  trans- 
formation from  apathy  to  lucidity  in  the  course  of  a  few 
minutes,  brought  about  by  arranging  a  slight  but  definite 
emotional  shock  to  the  patient,  namely,  by  mentioning  in  his 
presence  something  about  home  or  family.  One  bit  of  tech- 
nic  was  to  get  the  patient  to  write  or  dictate  a  letter  home. 

Regis  remarks  that  battle  dreams  of  this  nature  occasion- 
ally affect  alcoholics  in  garrison  or  at  home.  The  victim 
ought  not  to  be  hastily  committed  to  an  asylum,  but  should 
be  treated  in  a  military  neuropsychiatric  service  with  isola- 
tion chambers  and  open  wards.  Regis  organized  early  in 
the  war  at  Bordeaux  a  central  psychiatric  service  along  these 
modern  lines.  He  remarks  that  the  central  service  ought 
to  receive  not  only  patients  from  the  military  hospitals,  but 
also  patients  from  the  temporary  auxiliary  hospitals  of  the 
city  and  district  round  about.  A  pooling  of  the  military 
and  civilian  issue  upon  rational  lines  is  here  indicated. 

Regis  and  others  have  remarked  upon  the  necessity  of 
differentiating  these  battle  deliria  from  toxic  and  infectious 
psychoses. 


TREATMENT  AND   RESULTS  68 1 


Shell  explosion:  Deaf  mutism,  recovery  of  speech 
with  electrical  treatment;  deafness  cured  by  sug- 
gestion in  writing. 


Case  478.  (BuscAiNO  and  Coppola,  January,  191 6.) 
A  fusileer,  20  (mother  neurotic,  brother  hemiparetic  from 
infantile  disease;  patient  had  extreme  otorrhea  from  an  early 
otitis  media),  entered  the  army  January  15,  191 5.  He  was 
sent  to  the  Isonzo  in  May  and  was  slightly  injured  in  the 
nape  of  the  neck  and  the  left  calf  by  fragments  of  a  shell 
that  exploded  near  by.  He  was  picked  up  unconscious  and 
taken  to  the  hospital  at  Servignano.  There  he  was  given 
electric  treatment,  and  in  a  period  of  18  days  recovered  his 
speech,  passing  through  a  phase  of  stammering.  He  was 
sent  to  a  special  hospital  in  Florence,  still  deaf,  and  passed 
into  a  state  of  mental  excitement  with  visual  hallucinations 
of  soldiers.  He  was  given  chloral  and  bromide.  He  in- 
sisted that  he  was  incurably  deaf.  August  22,  he  was  ad- 
mitted to  Buscalno's  clinic,  completely  deaf,  slightly  stu- 
porous, somewhat  indifferent,  and  innocent  of  any  effort  to 
make  himself  understood  (contrary  to  the  habits  of  an  or- 
ganically deaf  person).  Simulation  could  be  excluded.  It 
was  possible  to  awaken  the  patient  during  sleep  by  auditory 
stimuli,  whereupon  he  opened  his  eyes  but  could  not  hear. 
He  talked  well  and  spontaneously,  telling  about  his  accident, 
reading  and  answering  by  signs.  He  was  assured,  —  always 
in  writing,  —  that  upon  the  following  Sunday  his  hearing 
would  be  restored.  Upon  that  day,  during  the  visit  of  a 
lady,  —  one  of  the  patient's  friends,  —  hearing  was  suddenly 
and  almost  completely  restored  in  the  left  ear.  The  patient 
was  so  moved  by  this  that  he  cried  when  the  physician  came. 
Upon  the  following  day,  he  gradually  began  to  hear  with  his 
right  ear.  A  slight  diminution  of  hearing  in  the  right  ear 
persisted,  however,  until  September  24,  and  was  associated 
with  headache  and  pains  in  the  left  ear  —  pains  which  the 
patient  compared  to  his  ear  pains  in  childhood  (remains  of 
otitis  with  retraction  of  the  tympanic  membrane). 


682  TREATMENT  AND  RESULTS 


Paraplegia :  Cured  by  administration  of  Iron  Cross. 


Case  479.     (NoNNE,  December,  191 5.) 

After  heavy  shelling  a  soldier  fell  for  two  days  into  a 
clouded  state  from  which  he  waked  with  complete  paraplegia 
of  the  lower  extremities,  and  total  anesthesia  from  the  pelvis 
downward  (reflexes  and  electric  excitability  normal). 

On  the  third  day  after  his  reception  in  Nonne's  wards, 
he  was  about  to  be  hypnotized  when  news  came  that  he  had 
been  promoted  to  a  lieutenantcy  and  had  received  the  Iron 
Cross.  He  fell  forthwith  into  hysterical  convulsions,  in  the 
midst  of  which  the  hitherto  paralyzed  legs  worked  perfectly 
well!  Even  after  the  hysterical  attack  was  over,  the  man 
could  still  move  his  legs  in  bed  normally,  but  had  absolute 
astasla-abasia.  Next  day,  with  deep  hypnosis,  markedly  im- 
proved. After  eight  more  days  of  hypnosis  the  new  lieuten- 
ant got  back  his  normal  gait. 


Shell-shock,  burial :  Mutism.     Cure  by  getting  drimk. 


Case  480.     (Proctor,  October,  1915.) 

A  patient,  25,  nine  years  in  the  service,  was  buried  in  a 
dugout  by  an  explosive  shell  at  Ypres,  June  17,  was  taken 
out  unconscious,  and  eventually  reached  the  hospital  at 
Versailles.  Consciousness  had  returned  a  few  days  after  the 
injury.  There  was  ringing  in  the  ears,  difficulty  in  hearing, 
and  inability  to  speak.  He  arrived  at  the  Duchess  of  Con- 
naught's  Hospital  at  Taplow,  July  12,  when,  aside  from  the 
above-mentioned  symptoms  and  a  rapid  heart  action  (108  at 
rest),  he  seemed  perfectly  well.  About  August  14,  he  began 
occasionally  to  refuse  solid  nourishment  and  remained  in  bed, 
eyelids  closed  but  twitching  at  times,  especially  when  spoken 
to.     He  resisted  having  his  eyelids  opened. 

August  27,  he  was  allowed  to  go  to  the  village  with 
companions,  and  got  drunk,  found  his  voice,  for  two  days 
talked  and  sang  incessantly.    Discharged  September  9,  cured. 


TREATMENT   AND    RESULTS  683 


Shell-shock  and  burial :  Mutism.     Cure  by  work  in 
a  vineyard  with  wine  to  drink. 


Case  481.     (Anon,  May,  191 6.) 

A  correspondent  of  the  British  Medical  Journal  reports  a 
case  of  cure  of  emotional  mutism.  This  robust  young 
soldier  at  Verdun  was  buried  by  the  explosion  of  a  shell  and 
was  thereafter  found  unable  to  speak.  A  week  later  he 
arrived  at  the  ambulance  in  the  interior,  and  was  still  mute. 
He  could  understand  what  was  said  to  him  without  difficulty, 
and  was  able  to  reply  by  signs.  He  did  not  even  move  the 
lips  when  requested  to  pronounce  such  words  as  mamma  and 
papa,  but  was  eventually  induced  to  whisper  these  words. 

The  laryngoscope  showed  complete  paralysis  of  the  vocal 
cords,  which  were  in  extreme  abduction  (it  was  possible  to 
see  several  tracheal  rings).  There  was  no  reaction  on  the 
part  of  the  pharyngeal  mucosa  upon  stimulation. 

A  fortnight  passed  without  restoration  of  speech,  though  at 
one  time,  not  having  bolted  the  closet  door,  the  patient  was 
startled  when  a  nurse  rushed  in,  and  he  said,  "Oh,  pardon, 
Madam."  The  mutism  persisted.  He  was  then  given  work 
in  the  vineyard,  plenty  of  wine  to  drink,  and  hard  work. 
After  a  time  (not  specified)  speech  suddenly  returned.  Ac- 
cording to  this  correspondent,  "  this  indeed  is  a  universal 
experience,  namely,  that  hard  manual  work  is  the  best 
remedy  for  such  functional  incapacities  of  traumatic  origin." 

Re  Cases  480  and  481,  compare  cures  by  anesthesia  with 
chloroform,  nitrous  oxid,  and  the  like. 

Re  gradual  cures  as  opposed  to  sudden  ones,  Dundas 
Grant  deprecates  violent  measures  in  the  treatment  of 
mutism  during  the  period  of  exhaustion  after  Shell-shock. 
How^ever,  Dundas  Grant  does  not  advocate  an  expectant 
treatment,  but  employs  a  gradual  reeducation  of  the  voice 
through  imitation  of  the  teacher.  The  voice  is  sometimes 
restored  at  a  sitting,  sometimes  gradually;  see,  for  example, 
Case  578  of  Briand  and  Philippe,  and  Case  586  of  MacCurdy. 


684  TREATMENT  AND  RESULTS 


Shell-shock,  unconsciousness :  Deafmutism :  Spon- 
taneous recovery  of  speech  and  gradual  recovery 
(several  months'  isolation)  of  hearing. 


Case  482.     (Zanger,  July,  1915.) 

A  musketeer  was  deafened  and  stunned  by  a  near-by 
shell  explosion.  On  coming  to,  he  found  no  wound,  but  was 
deaf  and  dumb. 

Speech  returned  after  ten  days,  and  hearing  partially,  but 
there  was  a  tonic  stuttering.  He  had  to  hunt  anxiously  for 
words,  talked  like  a  child  in  infinitives  and  telegram  style, 
although  he  could  express  himself  in  writing  perfectly  well. 

Hearing  improved  on  the  right  side  very  quickly,  but  on 
the  left  side  conditions  varied  from  total  deafness  to  subtotal 
deafness.  There  was  a  general  hyperesthesia  of  the  skin, 
pain  on  pressure  on  the  temples,  exaggeration  of  skin  and 
tendon  reflexes,  marked  tremor  in  both  hands.  The  man 
was  anxious,  depressed,  and  irritable.  During  caloric  tests 
of  the  vestibular  apparatus  in  the  course  of  the  next  few 
weeks,  the  man  had  an  hysterical  attack  of  crying  twice, 
following  which  all  the  phenomena  got  worse. 

Rest  and  isolation  from  all  such  influences  procured  an 
almost  complete  recovery  in  several  months. 

Re  differential  recoveries,  see  also  Case  585  of  Liebault,  in 
which  speech  was  recovered  by  suggestion  and  reeducation, 
and  hearing  by  a  process  of  reeducation  alone. 

Re  isolation,  Roussy  and  Lhermitte  remark  that  in  all  the 
psychoneuroses  of  war,  isolation  is  a  valuable  and  indeed 
an  indispensable  aid  to  psychotherapy.  The  application  of 
this  old  classical  method  of  Weir  Mitchell  reinforces  the 
persuasive  talk  of  the  doctor  on  the  day  of  admission,  allows 
the  man  to  think  over  the  promises  made  to  the  doctor,  and 
permits  longer  observation.  It  depends  on  the  case,  whether 
rigorous  isolation  on  limited  diet  shall  be  employed.  See 
below  a  general  discussion  of  the  psycho-electric  and  re- 
educative  method  employed  in  French  centres. 


TREATMENT   AND   RESULTS  685 


Marches ;  battles ;  slight  shell  wound  of  left  upper 
arm :  Hysterical  anesthesia  of  the  arm  and  tremors 
(NO  paresis).  Causes  slight  —  disease  obstinate 
(partly  explained  by  furloughs  among  sympathetic 
friends) . 


Case  483.     (BiNSWANGER,  July,  191 5.) 

A  soldier,  26,  without  heredity,  always  well,  in  long 
marches  and  several  battles  early  in  the  war,  August  23 
sustained  slight  shell  wounds  of  thighs  and  left  upper  arm. 
He  was  unconscious  about  five  minutes.  In  eight  days,  the 
wounds  were  healed,  and  all  movements  were  free. 

Immediately  after  the  trauma  the  arms  trembled,  and  at 
times  the  legs.  Treatment  was  instituted  (baths,  drugs, 
massage,  electricity),  but  without  result.  After  a  month's 
treatment  and  a  furlough  at  home,  the  patient  was  sent, 
January  3,  1915,  to  the  Jena  Nerve  Hospital.  He  was  a 
powerful  man  of  middle  size,  with  some  small  movable  scars 
on  the  left  upper  arm,  remains  of  the  shell  injury;  two 
similar  scars  of  the  gluteus  maximus.  The  deep  reflexes 
were  slightly  exaggerated,  as  were  the  skin  reflexes.  The 
touch  and  pain  sense  in  the  left  arm  was  absent  as  far  as  the 
shoulder  in  typical  segmental  fashion.  Arm  movements 
were  free;  there  was  an  occasional  tremor  in  both  arms, 
especially  the  left.  This  tremor  would  pronouncedly  in- 
crease upon  intentional  movements  and  with  emotion. 

He  said  that  about  two  weeks  before,  at  home,  he  had 
waked  up  in  the  night  and  lain  down  on  the  floor  beside 
his  bed,  feeling  giddy  in  his  head.  In  a  week  the  tremors 
had  diminished,  leaving  only  a  very  slight  tremor  of  the  left 
hand.  The  patient  went  to  considerable  pains  to  conceal 
his  tremor,  holding  his  hand  in  a  military  position  at  the 
seam  of  the  trousers,  on  the  medical  visit.  Sometimes  he 
would  succeed  in  making  the  tremor  quite  disappear.  Feb- 
ruary 5,  he  was  busy  about  the  ward  work,  going  errands 
and  carrying  trays.  He  would  intentionally  spare  his  left 
hand  in  this  work.     Upon  trying  gymnastic  exercises,  the 


686  TREATMENT   AND   RESULTS 

tremors  of  the  left  hand  and  also  of  the  right  reappeared. 
After  a  few  days  these  tremors  again  disappeared,  only  to 
come  back  on  the  12th,  when  there  was  a  constant  tremor 
also  when  the  patient  was  at  rest.  He  had  been  affected 
when  observing  another  patient  (8*).  Accordingly,  he  was 
separated  from  this  patient  and  put  in  a  psychiatric  ward. 
The  tremor  remained  of  varying  intensity,  sometimes  being 
absent  for  hours  together. 

Request  for  furlough  at  the  beginning  of  March  was  re- 
fused with  the  statement  that  it  would  be  granted  when  cure 
was  complete.  The  patient  was  inaccessible  to  psychothera- 
peutic influence.  He  was  always  of  a  friendly,  modest  de- 
meanor, sleeping  well,  and  performing  all  bodily  functions 
properly.  On  any  exertion  the  pulse  ran  to  134.  The 
heart  was  normal.     There  were  outbreaks  of  perspiration. 

March  26,  he  renewed  his  request  for  leave,  desiring  his 
Easter  furlough.  He  was  told  he  might  expect  it.  March 
31,  the  tremor  was  found  to  have  quite  disappeared.  Upon 
his  return,  April  12,  there  was  a  marked  tremor  of  the  left 
arm,  especially  of  the  wrist  joint,  which  again  disappeared 
after  some  days.  The  middle  of  June  he  was  released  as 
capable  of  garrison  duty  with  the  recruits. 

If  there  was  a  mechanical  factor  in  this  case,  it  must  have 
been  the  shaking-up  of  the  body  by  the  shell  explosion.  His 
skin  lesions  were  slight.  The  main  factor  was  doubtless  the 
emotional  shock.  The  tremor  supervened  upon  a  very  brief 
period  of  unconsciousness.  It  is  hard,  according  to  Bins- 
wanger,  to  explain  the  localization  of  the  cutaneous  anes- 
thesia without  the  development  of  a  corresponding  paresis. 
May  it  be,  inquires  Binswanger,  that  the  wound  of  the  left 
upper  arm  at  the  moment  of  the  setting-in  of  unconscious- 
ness, or  perhaps  at  the  moment  of  waking  from  unconscious- 
ness, directed  the  mind  forthwith  upon  the  left  arm  and  in 
this  way  produced  localized  disorder  of  sensation?  If  so, 
why  did  the  wound  of  the  gluteal  region  not  produce  cor- 
responding disorders  of  feeling  and  sensation  of  an  hysterical 
nature?     The  obstinacy  of  the  disease  stands  in  striking  dis- 

*  See  Case  8  of  Binswanger' s  article. 


TREATMENT  AND  RESULTS  687 

proportion  to  the  slightness  of  the  causative  factors  at 
work. 

According  to  Binswanger,  this  is  perhaps  due  to  the  long 
furlough  which  the  patient  had.  According  to  Binswanger's 
experience,  as  that  of  many  others,  home  works  badly  for 
these  hysterical  patients ;  their  friends  sympathize  with  them 
too  much. 

Re  furloughs,  Ballard  states  that  severe  Shell-shock  cases 
should  get  analogous  treatment  to  that  of  civilian  psychoneu- 
rotics, namely,  a  complete  removal  from  the  environment 
in  which  the  illness  began.  He  advocates  three  months' 
leave,  after  which  the  man  is  to  be  sent  to  a  convalescent 
home,  and  thence  to  a  command  depot.  He  states  that  if  a 
relapse  then  occurs,  such  a  patient  will  never  be  a  soldier. 
Ballard  would  allow  the  men  to  walk  about  with  their  "pals 
(not  with  escorts)."  Cimbal  remarks  that  German  data 
show  that  home  furloughs  should  be  avoided  in  every  in- 
stance where  possible.  Fiessinger  remarks,  on  the  basis  of 
English  experience,  that  a  Shell-shock  patient  treated  by 
rest,  suggestion,  and  manual  occupation  may  go  back  to  the 
line  "and  on  a  subsequent  occasion  prove  a  hero."  (See 
Case  474  of  Gilles.)  But  Forsyth  remarks  that  it  is  prob- 
ably injudicious  to  send  any  cases  of  Shell-shock,  with  few 
exceptions,  back  to  the  firing  line,  because  their  fighting 
value  has  been  permanently  deteriorated,  and  because,  if  the 
fear  of  return  to  the  trenches  is  removed,  recovery  is  more 
rapid.  The  experience  here  is  not  unlike  that  of  industrial 
accident  board  cases  with  rapid  recovery  after  the  decree  of 
compensation. 


688  TREATMENT  AND  RESULTS 


War    stress    in   a    volunteer   banker:    Hysterical 
seizures.     Treatment  by  hydrotherapy. 


Case  484.     (HiRSCHFELD,  February,  1915.) 

A  banker,  a  volunteer  (articular  rheumatism  at  three 
years;  at  18,  some  form  of  lung  and  tracheal  inflammation; 
tendency  to  fainting  spells  on  cold  days  —  heart  disease  was 
said  to  have  been  found),  as  a  result  of  the  strain  and  excite- 
ment of  the  war  had  hysterical  attacks  during  a  fortnight 
before  observation  in  hospital,  consisting  of  sensations  sud- 
denly developing  in  the  region  of  the  heart,  stiffness  of  the 
whole  body,  disorders  of  movement,  without  loss  of  con- 
sciousness. 

November  23,  1914,  he  was  examined  in  bed  in  the  dorsal 
position,  with  the  muscles  of  the  legs,  back,  and  neck  in  a 
state  of  tonic  contraction.  He  was  unable  to  answer  ques- 
tions. The  pupil  reactions  were  normal  in  the  seizure.  The 
attack  ceased  in  two  minutes,  as  the  result  of  hitting  heavy 
blows  on  the  chest  with  a  moist  handkerchief  and  the  threat 
of  a  strong  and  painful  application  of  the  electric  current. 
The  patient  then  got  out  of  bed  at  request,  walked  about  a 
little  incoordinately  for  a  time,  but  after  a  few  minutes  was 
able  to  walk  perfectly  and  to  talk  once  more. 

Examined,  November  25,  he  was  found  to  be  pale,  fairly 
well  nourished,  with  a  somewhat  accelerated  pulse,  and  a 
melancholy,  slightly  apathetic  expression.  A  systolic  mur- 
mur at  the  right  apex;  accentuation  of  secondary  pulmon- 
ary sound;  increased  knee-jerks;  trembling  of  the  lids 
(Rosenbach). 

By  December  12,  the  patient  was  completely  well.  The 
seizures  had  not  recurred.  The  treatment  was  by  hydro- 
therapy. A  preliminary  treatment  is  advocated  by  Hirsch- 
feld,  to  insure  peripheral  circulation,  either  by  light 
baths,  hot  douches,  or  packs.  More  important  than  this 
preliminary  treatment  is  the  cooling  off  process  by  means  of 
tepid  douches  or  partial  baths.  These  partial  baths  are 
given  at  28°  C.  for  the  intense  effect  of  the  cold.     Some- 


TREATMENT   AND   RESULTS  689 

times  this  treatment  can  be  concluded  with  a  dry  pack.  The 
patients  are  treated  by  Hirschfeld  three  times  a  week  with 
both  the  warming  and  the  cooHng  procedure. 

Re  hydrotherapy,  Mott  has  found  the  continuous  warm 
bath  of  great  value  in  Shell-shock  cases  coming  back  from 
France.  He  keeps  the  patient  in  the  water  from  a  quarter 
to  three-quarters  of  an  hour,  or  longer.  A  warm  bath  and 
a  drink  of  warm  milk  at  bedtime  may  permit  a  man  to  get 
on  without  hypnotics,  or  to  get  on  with  lesser  amounts  of 
hypnotics.  The  effect  of  these  baths  is  doubtless  largely 
somatic.  Some  writers  stress  the  suggestive  value  of  hydro- 
therapy as  well  as  of  electricity,  radiant  heat  baths,  and  the 
like  (Ballard).  A  neuropsychiatric  center  properly  equipped 
with  a  hydrotherapeutic  plant  can  do  therapeutic  work  by 
means  of  the  suggestion  afforded  by  a  cold  shower,  which 
may  act  quasi  miraculously,  like  electricity  (Roussy  and 
Boisseau).  In  fatigue  and  exhaustion  cases,  along  with  ad- 
renalin and  strychnin,  Aime  gives  mild  hydrotherapy  without 
other  sedatives.  Laehr's  free  sanatorium  at  Schonow  treats 
the  arythmia  and  tachycardia  cases  with  rest  and  hydro- 
therapy. 

Brasch  reports  rather  poor  results  with  hydrotherapy  in 
the  cardiac  neuroses.  Weichardt  has  used  the  continuous 
bath  as  a  form  of  psychotherapy  and  permits  the  symp- 
toms of  psychoneurosis  to  subside  therein. 


690  TREATMENT   AND    RESULTS 


Shell-shock :  low  blood  pressure  :   Pituitrin. 


Case  485.     (Green,  September,  1917.) 

A  lance  corporal  of  the  Expeditionary  Force,  26,  went  to 
France  feeling  very  fit,  February,  1916.  He  was  blown  up  by 
a  shell  July  i,  and  faintly  remembered  crawling  out  of  some 
water.  He  came  to  in  a  dugout,  dumb  and  partially  deaf, 
and  was  blind  for  a  few  minutes.  August  17,  he  was  ad- 
mitted to  Mott's  wards  at  Maudsley,  mute  but  with  hearing 
normal.  The  hands  were  dusky,  sweating,  cold,  and  slightly 
tremulous.  He  was  given  to  battle  dreams  and  used  to 
wake  in  a  sweat  and  terror  after  a  pantomime  of  bomb- 
throwing.  He  had  headache  and  was  depressed.  He  com- 
plained of  feeling  cold  and  the  surface  temperature  was 
subnormal.  The  blood  pressure  was  also  subnormal  (accord- 
ing to  Green,  nightmares  are  most  marked  in  cases  with  low 
blood  pressure;  these  are,  in  fact,  severer  cases  of  Shell-shock 
than  cases  with  high  blood  pressure;  only  10  of  27  cases  with 
blood  pressure  above  120  showed  nightmares). 

September  25,  he  was  able  to  speak  in  a  whisper.  The 
dreams  had  become  less  terrifying.  The  other  symptoms 
had  been  slowly  improving. 

November  25-28,  all  of  the  symptoms  returned  upon  hear- 
ing the  death  of  his  brother  in  action. 

The  man  was  now  put  on  extract  of  pituitrin  gr.  2,  t.d.s. 
(better  results  are  claimed  by  Green  from  pituitrin  extract 
than  from  pituitary  fluid  injections,  as  these  sometimes  cause 
dizziness,  of  which  no  case  treated  with  extract  complained). 
As  in  other  cases,  the  extract  was  immediately  followed  by 
an  increase  in  blood  pressure,  a  general  improvement  and  a 
diminution  of  headache  and  depression.  The  bomb-throw- 
ing pantomimes  still  persisted,  but  the  patient  was  less  weak 
on  waking.  The  treatment  was  continued  for  seven  days, 
whereupon  the  surface  temperature  began  to  rise  and  the 
patient  himself  felt  that  he  was  much  warmer.  The  pitui- 
trin was  discontinued  after  a  month's  treatment,  yet  the  im- 
provement persisted.  The  man  was  boarded  out  of  the  army 
and  in  March,  1917,  wrote  that  he  was  still  feeling  better. 


AUG.  2B                  6  SEPT.       16 

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Blood  pressure,  surface  temperature,  and  pulse  in  a  case  of  fimctional  mutism,     fa)  On  admission, 

troubled  by  nightmare,    (b)  Able  to  speak  in  a  whisper,    (c)  Much  depressed  after  bad  news. 

(d)  Put  on  pituitrin.     (e)  Marked  general  improvement,      (f)  Taken  off  pituitrin. 


A — I  Showing  the  effect  of  pituitrin  on  the  blood  pressure  and  surface  temperature.     Each  dot  is  one 

week's  interval.     +  is  the  pressure  when  the  first  dose  was  given.     0  is  the 

point  at  which  the  pituitrin  was  discontinued. 


SHELL-SHOCK,  PITUITRIN,  AND  BLOOD  PRESSURE  (EDITH  GREEN) 


TREATMENT   AND   RESULTS  69 1 


Various  treatments  of  a  contracture  of  hand. 


Case  486.     (DuvERNAY,  November,  19 15.) 

A  chasseur,  22,  received  a  bullet  wound  in  the  anatomical 
snuffbox,  the  bullet  emerging  under  the  styloid  process  of 
the  radius,  having  traversed  the  back  of  the  hand  without 
striking  bone.  Healing  was  rapid,  but  the  hand  assumed  a 
peculiar  position.  The  second  and  third  phalanges  of  the 
fingers  were  extended,  whereas  the  first  phalanx  was  flexed. 
The  four  fingers  were  as  if  glued  together.  Both  phalanges 
of  the  thumb  were  flexed,  the  wrist  was  in  extension,  and 
the  tendon  of  the  pal  maris  seemed  contractured.  The 
fingers  could  not  be  moved  and  the  wrist  was  very  mobile. 
There  was  pain  on  attempts  to  move  the  hand  passively, 
and  small  clonic  contractions  were  made  by  the  fingers. 
There  were  no  sensory  disorders,  but  there  was  a  maceration 
of  the  interdigital  spaces. 

Mechanotherapy  accelerated  the  contracture,  and  mas- 
sage, motor  reeducation,  bromides,  and  sedative  drugs,  had 
no  effect.  Under  kelene-anesthesia  the  contracture  would 
disappear.  In  January,  1915,  the  hand  was  put  up  in  plas- 
ter in  a  position  opposite  to  the  contracture.  The  intense 
pain  of  the  first  days  was  treated  by  opium.  The  patient 
was  sent  on  leave,  and,  at  the  end  of  two  months,  the  plaster 
was  removed;  but]  the  hand  at  once  resumed  its  faulty 
position,  and  attempts  to  alter  its  position  again  provoked 
pain.  Elastic  traction  was  then  tried  for  six  weeks,  and  the 
bad  position  was  somewhat  modified  but  not  improved  by 
hyperextending  the  second  phalanx  on  the  first,  and  putting 
the  third  in  slight  flexion  on  the  second.  Hot  compresses 
were  unsuccessful  also.  May  14,  1915,  the  position  was  still 
irreducible;  there  was  no  R.  D.  or  electrical  hyperexcitabil- 
ity.  This  was  not  a  question  of  radial  paralysis,  since  finger 
extension  was  distinct;  nor  a  paralysis  of  the  median,  since 
the  thumb  was  flexed.  The  contracture,  in  fact,  does  not 
affect  a  special  nerve  territory,  and  the  disorder  is  in  the 
ulnar,  radial,  and  median  territories. 


692  TREATMENT  AND  RESULTS 


Orthopedic  case. 


Case  487.     (SoLLiER,  November,  1916.) 

A  patient  suffered  from  a  rupture  of  the  peroneal  nerve  in 
its  lower  part,  September,  1915,  and  had  operation  scars 
before  and  behind  the  external  malleolus.  He  was  immo- 
bilized for  45  days  at  first,  and  then  for  30  days,  with  the  foot 
in  extension  on  account  of  the  pain  produced  in  the  endeavor 
to  put  it  into  normal  position.  A  6  cm.  atrophy  was  then 
found  to  affect  the  calf,  and  there  was  a  fibrous  retraction 
of  the  tendo  Achillis  and  of  the  calf  muscles.  There  was 
no  anesthesia,  the  toes  moved  easily,  the  foot  was  fixed  in 
equinus,  with  about  7  cm.  of  the  heel  above  the  ground.  He 
was  placed  in  various  orthopedic  institutions  and  was  treated 
with  mechanotherapy,  but  without  result. 

At  the  neurological  center,  however,  in  six  weeks,  he  was  got 
to  walk,  with  his  heel  on  the  ground,  by  means  of  massage  and 
manual  mobilization.  The  atrophy  diminished  a  centimeter 
and  the  foot  became  mobile  in  all  directions. 

According  to  Sollier,  mechanotherapy  by  means  of  appa- 
ratus is  apt  to  be  ineffective,  especially  in  contractures,  be- 
cause its  action  ceases  the  moment  it  ought  to  commence, 
namely,  w^hen  the  patient  is  beginning  to  react  a  little  pain- 
fully after  recovery  from  anesthesia.  In  cases  of  retraction, 
mechanotherapy  with  apparatus  does  not  allow  the  proper 
combination  of  massage  with  progressive  mobilization. 

Re  orthopedic  cases,  Jones  classes  the  conditions  that 
create  an  orthopedic  case  under  four  heads  (note  espe- 
cially the  fourth) : 

1.  Mechanical  injury  to  bone,  joint,  muscle,  or  nerve. 

2.  Atrophy  and  disease  of  these  structures  primarily  due 

to  the  injury. 

3.  Incoordination  of  movement  due  to  disease  of  the 

brain  —  a  result  of  atrophy  and  disease  of  periph- 
eral structures. 

4.  Psychological  conditions  which  can  be  overcome  by 

reeducational  processes. 


ANKLE 
EXTEXSIOX 


FLEXION 

AND 

EXTENSION 


ELBOW 

FLEXION 

AND 

EXTENSION 


ANKLE 
EXTENSION 


ROTATION 
OF   HIP 


CIRCUM- 
DUCTION 
OF  THIGH 


MECH.\NOTHERAPY   (COLOLIAN) 


TREATMENT  AND  RESULTS  693 


Favorable  effects  of  lumbar  puncture. 


Case  488.     (Ravaut,  August,  1915.) 

An  accountant,  20,  in  the  135th  infantry  sustained  shock 
from  mine  explosion  near  his  trench,  March  6.  He  was 
kept  two  days  at  the  reUef  station.  March  8,  at  the 
ambulance,  he  did  not  appear  to  understand  questions  and 
had  a  fixed  stare.  He  complained  of  a  violent  headache  and 
kept  pressing  his  head  between  his  hands.  He  kept  looking 
about  him  anxiously,  and  the  slightest  noise  made  him  jump. 
He  would  mutter  a  few  incomprehensible  words,  and  in  reply 
to  a  question  would  give  only  the  last  phrase  which  he  hap- 
pened to  have  been  saying.  Lumbar  puncture  showed  a 
very  slight  excess  of  albumin.  Next  day,  he  answered  his 
name.  March  12,  he  could  speak  in  monosyllables,  and  he 
began  to  understand  what  was  said.  After  the  lumbar 
puncture,  the  headache  disappeared  and  did  not  set  in  again. 
March  13,  he  began  to  be  able  to  write  and  say  short  phrases. 
March  16,  expression  was  good  though  hesitant,  and  the 
patient  wrote  a  letter  to  his  parents,  telling  about  his  shock. 
Lumbar  puncture  showed  that  the  albumin  was  now  normal. 
From  the  rear,  April  5,  the  patient  sent  Ravaut  a  postcard 
in  perfect  form,  telling  how  he  was  ready  to  go  back  to  the 
front. 

Re  lumbar  puncture,  Imboden  quotes  Podmanizky  as  hav- 
ing used  lumbar  puncture  as  a  method  of  suggestion  for  the 
cure  of  abasia.  See  also  cases  560  and  561,  in  which  Claude 
cured  two  cases  of  dysbasia  by  the  device  of  stovaine  anes- 
thesia of  the  spinal  cord.  Pastine  also  has  a  case  in  which 
a  slight  improvement  was  produced  on  removal  of  cerebro- 
spinal fluid,  and  a  sudden  and  complete  cure  was  brought 
about  by  the  second  puncture,  a  very  painful  tap.  Pastine's 
case  is  thought  by  him  (19 16)  to  be  in  part  at  least  organic. 


694  TREATMENT  AND   RESULTS 


Bullet    wound    of    forearm:    Hysterical    clenching 
of  fist.     Recovery  by  fatiguing  the  flexors. 


Case  489.     (Reeve,  September,  191 7.) 

A  soldier,  28,  was  thrice  wounded  between  August  18,  1914, 
and  July  14,  1916.  The  third  time,  a  bullet  passed  through 
the  fleshy  part  of  the  forearm,  whereupon  the  hand  became 
clenched  and  remained  so  after  the  wound  was  surgically 
healed.  As  a  case  of  war  neurosis,  the  man  was  treated  by 
electricity,  massage,  passive  movements,  and  fixation  in  a 
straight  splint  during  a  period  of  nine  months,  without  result. 
Hewasadmitted  to  IMaghull  Military  Hospital, ''April  18,  1917. 

Two  days  after  admission  a  treatment  was  given  whose 
principle  consists  in  producing  a  condition  of  fatigue  in  the 
muscles  responsible  for  contracture.  This  fatigue  is  produced 
by  continuous  passive  movements  in  a  direction  opposed  to 
the  normal  action  of  the  muscles  in  question.  Many  hours  of 
forcible  movement  are  sometimes  necessary  in  the  case  of  the 
more  powerful  muscles  before  the  limp,  toneless  fatigue  con- 
dition is  brought  about.  Relays  of  men  are  told  off  for  this 
purpose.  Patients  are  got  to  assist  in  the  work,  particu- 
larly such  as  have  been  cured  by  the  treatment.  Also,  the 
patient  is  himself  told  about  the  nature  of  spasms  and  the 
relief  which  the  method  will  bring.  This  patient  was  told 
that  after  the  flexor  muscles  were  fatigued  they  would  no 
longer  be  able  to  pull  the  fingers  into  the  clenched  position, 
whereupon  the  antagonistic  muscles  on  the  back  of  the  fore- 
arm would  begin  to  work. 

The  fingers  were  forcibly  opened  w^ithout  interruption  for 
six  hours,  in  each  case  as  soon  as  the  fingers  closed  into  the 
palm.  In  a  few  hours  they  began  to  return  more  slowly,  and 
at  the  end  of  the  six  hours  remained  extended.  The  extended 
position  was  still  found  the  following  morning.  The  exten- 
sor muscles  were  feeble  in  action,  but  improved  day  by  day. 
The  spasm  did  not  return.  The  patient  was  discharged 
July  2,  1 91 7,  about  two  and  a  half  months  after  admission  to 
Maghull.     The  hand  was  now  strong  and  useful. 


TREATMENT   AND    RESULTS  695 


Bullet    through    shoulder    girdle:    Hysterical    ad- 
duction of  arm.     Treatment  by  induced  fatigue. 


Case  490.     (Reeve,  September,  1917.) 

A  man,  29,  was  in  hospital  more  than  two  years  before  the 
Reeve  fatigue  treatment  was  applied  to  a  functional  con- 
tracture. This  man  had  a  bullet  pass  through  the  right 
scapula  and  out  the  pectoralis  major,  June  4,  191 5,  was  (ac- 
cording to  patient's  story)  operated  two  months  later,  then 
further  operated  for  drainage  of  septic  wounds,  and  from 
August,  191 5,  had  his  arm  fixed  to  the  side,  going  into  spasm 
at  any  attempt  to  move  it  passively.  The  elbow  was  ex- 
tended and  at  first  the  fingers  were  tightly  flexed  and  wrist 
extended.  The  finger  flexion  and  wrist  flexion  cleared  in 
March,  1917,  and  recurred  in  May.  Electrical  massage  in 
June,  1917,  yielded  free  movement,  but  the  spasm  returned. 

The  man  was  admitted  to  Maghull,  June  12,  191 7,  that  is,  a 
little  over  two  years  after  his  injury.  The  arm  sprang  back  to 
the  side  like  a  clasp  knife  on  being  released.  The  wrist  and 
fingers  were  moved  freely.  Three  days  after  admission  the 
elbow  was  forcibly  flexed  for  some  hours,  whereupon  the  spasm 
disappeared.  Next  day  the  arm  was  forcibly  abducted  and 
reabducted:  for  four  or  five  hours  the  arm  could  be  volun- 
tarily abducted.  Two  assistants  were  necessary,  such  was 
the  force  of  the  adductor  contraction.  At  the  end  of  a 
week  the  patient  was  found  able  to  lift  his  hand  to  the  back 
of  his  head.     There  was  no  longer  spasm. 

Re  abrupt  treatments,  amongst  which  Reeve's  treatment 
by  Induced  fatigue  may  be  counted,  Bablnski  and  Froment 
consider  that  abrupt  treatment  is  far  superior  to  slower 
psychotherapy  combined  with  isolation,  whether  or  not  we 
are  dealing  with  a  recent  or  an  old  disease.  So  far  as  psy- 
chotherapy goes,  Babinski  wants  to  obtain  a  definite  im- 
provement, if  not  a  cure,  on  the  first  application  of  treat- 
ment. According  to  Babinski,  the  patient's  faith  in  his 
physician's  power  to  cure  him  is  most  active  at  this  first 
meeting,  whose  emotionality  favors  the  cure. 


696  TREATMENT   AND   RESULTS 


Burial  and  bruises  of  back :  Hysterical  cross-legs. 
Treatment  by  induced  fatigue  of  contractured 
muscles. 


Case  491.     (Reeve,  September,  191 7.) 

A  man,  32,  was  buried  by  a  shell  and  bruised  about  the 
back,  August  2,  1916.  He  was  bedfast  until  February,  191 7. 
Every  attempt  to  move  the  legs  brought  on  tremors.  He  was 
then  allowed  up;  but  the  attempt  to  walk  caused  one  foot 
to  knock  the  other,  and  his  ankles  became  bruised,  necessi- 
tating cotton  wool  pads  for  feet. 

He  was  admitted  to  Maghull,  June  12,  with  one  leg  crossed 
over  the  other  and  the  thigh  adductors  spastic,  especially 
on  the  right. 

The  fatigue  treatment  was  carried  out  in  dorsal  decubitus, 
each  leg  being  pulled  by  a  man,  and  the  separation  repeated 
when  necessary.  Four  hours  a  day  for  three  days  of  this 
work  finally  reduced  the  spasm  so  that  the  patient  was  able 
to  walk  with  assistance.  On  the  sixth  day  he  walked  a  mile 
without  assistance.     The  spasm  has  not  returned. 

Re  leg  contractures,  Berard  got  successful  results  by  con- 
tinuous extension  combined  with  injections  of  i  per  cent 
novocain  into  the  sciatic  nerve  trunk  and  the  contractured 
muscles.  According  to  Bablnski  and  Froment,  there  ought 
to  be  an  almost  certain  cure  of  any  genuine  hysterical  state. 
They  quote  the  observations  of  Souques,  Melge,  Albert 
Charpentler,  Clovis  Vincent,  Roussy,  and  Leri  as  proving 
this  claim. 

The  Reeve  method,  so  far  as  it  is  psychotherapeutic,  bears 
a  resemblance  to  Clovis  Vincent's  first  stage  of  what  the 
poilu  calls  torpillage,  namely,  the  stage  of  crisis  and  of  in- 
tensive reeducation.  But  Clovis  Vincent  uses  in  his  direct 
and  forcible  reeducation  the  galvanic  current. 


TREATMENT   AND   RESULTS  697 


Bullet  wound  of  neck :  Hysterical  torticollis.    Treat- 
ment by  induced  fatigue. 


Case  492.     (Reeve,  September,  191 7.) 

A  soldier,  20,  had  a  bullet  pass  through  the  back  of  the 
neck,  July  10,  1916,  and  returned  to  his  depot  surgically  well 
October  i.  A  fortnight  later  a  Zeppelin  raid  turned  his 
troop  out  in  the  middle  of  the  night,  and  on  the  morrow  the 
man's  neck  was  twisted  around  and  inclined  upon  the  left 
shoulder. 

Treatment  followed  in  various  hospitals,  with  fixation  in 
the  corrected  position  by  plaster  of  Paris  but  without  result. 
The  patient  was  admitted  to  Maghull,  April  18,  191 7,  with 
spasm  of  left  trapezius  and  right  sternomastoid  muscles. 
Under  hypnosis  the  deformity  could  be  easily  corrected. 
Unfortunately,  it  returned. 

The  fatigue  treatment  described  by  Reeve  was  started  a 
week  after  admission  to  Maghull.  The  neck  was  forcibly 
straightened  and  restralghtened  upon  return  to  its  twist.  In 
a  few  hours  the  contracting  muscles  had  become  fatigued; 
the  neck  was  straight. 

The  next  day  the  deformity  returned  slightly.  The 
fatigue  treatment  was  repeated.  The  patient  was  discharged 
well,  July  2. 


698  TREATMENT  AND  RESULTS 


Burial  by  shell  explosion:  Abasia,  tremors.     Claw 
foot  persistent  two  years  cured  by  induced  fatigue. 


Case  493.     (Reeve,  September,  1917.) 

A  man,  24,  buried  by  a  shell,  February,  191 5,  had  had  a 
functional  "  claw  foot  "  for  more  than  two  years,  cured  by 
the  Reeve  fatigue  treatment  in  less  than  a  week.  According 
to  Reeve,  claw  foot  is  perhaps  the  most  common  of  the  war 
contractures,  particularly  intractable,  and  often  seen  out  of 
hospital  with  an  "  inside  splint." 

After  his  burial  this  man  could  not  walk,  had  tremors,  was 
in  bed  for  four  months  and  on  getting  up  showed  strongly  in- 
verted foot.  Three  months'  splint  treatment,  strong  faradic 
currents,  massage,  passive  movements,  special  boots  with 
leather  wedges  to  tilt  the  foot  over,  were  methods  of  treat- 
ment tried,  but  unsuccessful.  At  Maghull  from  November 
18,  1 9 16,  he  was  treated  by  exercises,  passive  movements, 
suggestive  and  reeducative  measures,  and  after  a  few  months 
got  about  without  sticks. 

The  claw  foot  continued.  Toward  the  end  of  June,  191 7, 
the  feet  were  forcibly  flexed  and  everted  for  eight  hours.  The 
deformity  disappeared,  but  returned  slightly  next  day.  Fur- 
ther fatigue  treatment  for  eight  hours  caused  the  spasm  to 
cease  permanently.  He  was  discharged  quite  normal,  July 
20,  191 7.  Reeve  remarks  that  this  fatigue  method  might 
be  applicable  to  certain  hysterical  contractures  in  civil  prac- 
tice. 


TREATMENT  AND   RESULTS  699 


Skull  trauma  over 

right  eye 

:    Delirium, 

febrile? 

post-traumatic?   exhaustive? 

Operation : 

Epilepti- 

form  excitement. 

Later,  expl 

osive  diathesis:  Op- 

eration:   Euphoria. 

Seizures 

and    slight 

mental 

change. 

Case  494.     (BiNSWANGER,  October,  191 7.) 

A  soldier  (brother  choreic,  sister  infantile  palsy)  had  had 
measles  at  13  and  in  his  fever  climbed  out  of  bed  upon  a 
couch,  fell  from  the  couch  and  was  found  by  his  mother 
lying  on  the  floor.  He  was  of  moderate  intellectual  grade, 
of  an  emotional,  passionate  Saxon  nature  and  had  now  and 
then  been  intoxicated. 

In  September,  19 14,  he  was  wounded  over  the  right  eye. 
He  did  not  lose  consciousness  but  concluded  that  he  could 
not  get  back  to  his  own  lines  on  account  of  the  enemy  fire. 
Using  a  knapsack  to  cover  his  head,  he  lay  down  for  twenty- 
four  hours,  until  rescued  by  a  passing  body  of  the  sanitary 
corps  who  were  about  to  leave  him  for  dead  when  he  called 
loudly  to  them. 

He  was  very  weak  in  hospital  and,  towards  the  evening  of 
the  day  after  receiving  his  injury,  he  must  have  fallen  into 
some  sort  of  psychotic  state  lasting  ten  days.  For  this  he 
remained  quite  amnestic,  although  he  was  told  by  comrades 
that  he  had  hallucinations  and  had  scolded  and  yelled,  hear- 
ing voices.  Apparently  there  were  situation-deliria  —  the 
call  to  go  over  the  top.  Temperature,  which  had  run  to  38.8, 
after  ten  days  sank  to  normal,  and  consciousness  cleared  up. 

Was  this  a  case  of  protracted  febrile  delirium?  Or  of 
psychosis  due  to  commotio  cerebri,  that  is,  an  effect  of  height- 
ened intracranial  pressure?  Or  was  it  exhaustion-delirium 
following  loss  of  blood,  sleep  and  food? 

But  this  was  not  the  end.  The  wound  suppurated,  and 
in  May,  191 5,  eight  months  after  the  Injury,  operation  was 
performed  to  relieve  this  abscess.  Temperature  immedi- 
ately rose  to  from  38.4  to  38.6,  the  fever  lasting  three  days, 
and  a  second  psychotic  phase  with  complete  amnesia  entered. 


700  TREATMENT  AND  RESULTS 

He  went  into  this  phase  immediately  after  recovering  from 
the  operative  narcosis,  looking  wildly  about  and  cursing  the 
sister.  The  patient  was  violently  excited  and  was  put  in  a 
straight  jacket  on  the  second  day.  This  phase  may  be  re- 
garded as  one  of  epileptiform  excitement  with  delirium.  The 
operation  may  have  played  a  part  in  the  psychosis. 

There  were  no  further  psychotic  phenomena  which  could 
be  attributed  in  any  way  to  commotio.  There  were,  however, 
attacks  of  cortical  origin  and  emotional  seizures.  The 
patient  became  emotionally  excitable  and  lost  all  inhibitions 
against  expression  of  emotion,  such  as  crying.  Once  he  ac- 
tually tried  to  suppress  his  emotion  with  a  noose  about  his 
throat.  He  became  seclusive  and  withdrew  within  himself 
—  a  victim  of  Kaplan's  explosive  diathesis,  or  of  Bonhoef- 
fer's  emotional  hyperesthetic  defect  condition. 

A  second  operation  was  performed  in  September,  191 6, 
to  loosen  the  brain  scar,  and  a  large  splinter  of  bone  was 
removed.  During  the  operation,  under  local  anesthesia, 
there  was  a  severe  cortical  seizure  with  complete  disappear- 
ance of  the  reflexes.  Ether  was  then  administered.  Later, 
in  the  same  day,  there  were  several  minor  cortical  attacks. 

After  this  operation  the  man's  emotional  status  changed; 
he  was  no  longer  irritable  or  exclusive,  but  became  slightly 
euphoric  and  contented.  He  received  during  the  next  two 
weeks  four  tablets  of  Sedobrol  and  for  a  long  time  thereafter 
two  tablets  daily.  There  were  never  any  phenomena  of 
bromidism  or  any  suggestive  effects  of  the  bromides. 

The  first  attack  after  the  second  operation  came  in  Novem- 
ber, 1 9 16,  and  was  follow^ed  by  slight  dysarthria.  Repeated 
attacks  followed  which  were  attributed  to  contractions  in  the 
scar.  Accordingly,  a  third  operation  was  performed  and  an 
attempt  was  made  to  bridge  over  a  defect  in  the  right  frontal 
bone.  The  man's  emotional  status  remained  good  after  the 
operation,  but  further  attacks  appeared  six  weeks  later  and 
there  were  spells  of  dizziness.  Occasionally,  in  process  of 
thinking,  he  said  something  stuck  in  between  his  thoughts. 
Sometimes  thinking  broke  off  sharply  as  if  he  had  cut  through 
a  wire  with  an  electrical  current  in  it.  There  was  a  slight 
reduction  in  attention  and  a  slightly  increased  fatiguability. 


TREATMENT  AND   RESULTS  70I 


Hard  service;    shell  explosion  with  loss  of  teeth: 
Vomiting.     Cure  by  restoration  of  self-confidence. 


Case  495.     (McDowell,  January,  1917.) 

A  married  reservist  was  called  up  at  the  outbreak  of  the 
war  and  went  through  Mons,  the  Marne,  and  the  Aisne  and 
was  finally  blown  up  by  a  shell  at  Ypres.  Early  in  Novem- 
ber, 1 9 14,  he  lost  his  speech  but  got  it  back  in  time  to  get 
home  for  Christmas.  A  number  of  teeth  had  been  lost  in  the 
injury.  Vomiting  began  first  in  England.  While  on  leave 
at  home  he  vomited  at  every  meal.  Asked  whether  it  was 
his  food  or  his  thoughts,  he  said,  "  You  are  quite  correct, 
Sir,  you  know  I  have  always  been  with  thinking." 

Under  medical  care,  June,  191 5,  he  was  found  suffering 
from  hesitating  speech,  general  tremulousness  and  emotion- 
ality. He  worried  a  great  deal  on  account  of  money  matters 
at  home.  He  lay  awake  thinking.  A  child  became  ill  and 
died,  and  all  the  while  he  got  worse,  "  thinking  all  the  time." 

It  was  explained  to  him  that  the  vomiting  was  a  matter  of 
emotions.  The  lost  teeth  were  replaced  by  false  ones.  As  he 
began  to  get  control  of  his  emotions,  he  vomited  less  and  in- 
creased in  weight.  Finally  he  was  boarded  for  discharge  and 
was  sick  again  on  the  day  of  the  meeting.  A  fortnight  later 
when  sent  to  sign  discharge  papers  he  vomited  once  more. 

According  to  McDowell,  the  vagus  may  possibly  be  in- 
criminated as  a  cause  of  these  gastric  disturbances.  Prac- 
tically, the  vomiting  is  a  result  of  emotional  stress.  The 
cure  is  to  produce  insight  on  the  part  of  the  patient,  the  re- 
moval of  worry  and  the  restoration  of  self-confidence. 

MIchell  Clarke  cured  such  cases  with  milk  diet. 

Roussy  and  Lhermitte  find  hysterical  vomiting  to  be  rela- 
tively common  and  as  a  rule  without  difficulty  in  diagnosis; 
but  they  remark  that  there  is  often  some  underlying  organic 
condition  to  be  sought  for  and  treated  after  the  neuropathic 
element  has  vanished.  They  remark,  also,  that  there  is  no 
tendency  to  spontaneous  cure  of  the  disease.  They  advocate 
a  strict  dietetic  regime  and  psychotherapy. 


702  TREATMENT  AND   RESULTS 


Cure   of    self-accusatory    ("  started    retreat    from 
Mons")  and  other  delusions  by  *'autognosis." 


Case  496.     (Brown,  January,  1916.) 

Capt.  William  Brown,  in  the  discussion  at  the  Section  of 
Psychiatry  of  the  Royal  Society  of  Medicine,  January  25, 
19 1 6,  speaks  of  a  method  of  treatment  which  he  calls  autog- 
nosis  —  a  method  of  giving  the  patient  self-knowledge,  by 
revealing  to  the  patient  through  his  own  confessions  the 
cause  of  mental  change  leading  to  his  symptoms.  One  of 
Brown's  examples  is  that  of  a  sergeant  in  the  firing-line 
during  the  retreat  from  Mons.  He  was  admitted  to  MaghuU 
with  the  delusion  that  people  thought  he  had  given  the  signal 
for  the  retreat  from  Mons  on  a  silver  whistle,  a  shooting  prize 
of  his.  German  officers  used  silver  whistles  that  made  a 
note  like  his  own.  In  fact,  he  had  other  like  delusions,  such 
as  that  people  thought  him  responsible  for  an  Edinburgh 
railroad  accident  in  connection  with  his  troop-train.  A 
German  spy  might  have  heard  this. 

In  the  process  of  procuring  autognosis,  Capt.  Brown  found 
that  at  the  age  of  12  this  man  had  been  falsely  accused  of 
stealing  pork  pies  from  a  shop,  and  had  been  brought  before 
a  magistrate.  In  point  of  fact,  he  proved  an  alibi,  but  he  was 
greatly  worried  by  the  charge.  According  to  Capt.  Brown, 
this  incident  of  the  insistence  of  the  false  accusation  was  the 
beginning  of  his  tendency  to  delusions.  In  two  months'  time 
there  was  a  remarkable  improvement. 

Re  psychoanalysis,  autognosis  and  various  modifications, 
Forsyth  remarks  that  when  the  acute  stage  is  passed,  the 
Shell-shock  case  becomes  an  everyday  neurosis  In  which  war 
experiences  are  merely  the  latest  phases  In  the  patient's 
life,  and  that  psychoanalysis  may  then  become  necessary. 
Eder  regards  the  "mechanisms"  of  what  he  terms  "war 
shock"  as  the  Freudian  mechanisms  of  hysteria,  and  has 
commended  psychoanalysis  for  a  few  cases,  preferring  hyp- 
notism for  acute  cases.  Adrian  and  Yealland  decry  psycho- 
analysis on  the  score  of  time  limitations. 


TREATMENT  AND   RESULTS  7^3 


Deafmutism  in  three   men   shell-shocked  at  one 
time. 


Cases  497,  498,  499.  (Roussy,  April,  191 5.) 
There  were  three  Zouaves  in  a  first-Hne  trench  north  of 
Arras,  January  14,  191 5,  who  were  blown  up  by  a  bomb  thrown 
from  the  enemy  trench  some  hundreds  of  meters  away,  by  a 
mortar,  a  crapouillaud.  This  projectile  burst  with  a  great 
noise,  louder  than  that  of  a  bomb,  and  made  a  very  strong 
windage.  A  dozen  men  were  blown  under  the  trench  wall, 
just  after  entering  the  trench;  two  were  killed;  and  the 
others,  most  of  whom  had  been  buried  to  the  neck,  were 
pulled  out  and  carried,  trembling,  to  the  nearest  relief  post. 
Two  of  the  three  Zouaves  were  bleeding  at  nose  and  ears,  and 
all  three  were  absolutely  deaf  and  mute.  Evacuated  to  an 
ambulance,  and  thence  to  Paris,  they  arrived  at  Val-de-Grace, 
January  17,  that  is  to  say,  three  days  after  the  shell  burst. 
They  communicated  with  the  attendants  by  signs;  one  got 
hold  of  paper  and  wrote  several  hours  in  the  day  rapid  notes 
about  the  accident.  However,  hysteria  or  pure  simulation 
was  suspected  in  these  three  Zouaves,  and  they  were  placed  in 
small  separate  rooms.  They  were  informed  through  the 
physician's  remarks  to  his  staff  that  these  were  cases  of  noth- 
ing but  simple  nervous  shock  such  as  we  had  often  observed, 
and  the  claim  was  made  that  they  would  be  completely  well 
either  on  the  morrow  or  the  day  after. 

On  the  morrow,  two  of  them  partially  recovered  hearing 
and  got  back  their  voices.  They  became  loquacious  and 
began  to  tell  about  the  battle.  The  day  after,  the  third 
patient  began  to  speak.  Two  of  them  showed  traces  of 
auricular  hemorrhage,  and  in  fact,  actual  ear  lesions  were 
found  in  all  three.  One  had  a  suppurative  right  middle  ear, 
with  perforation;  another  had  both  drums  perforated  and  a 
suppurative  middle  ear,  also  on  both  sides.  The  third,  who 
recovered  his  speech  after  the  others,  had  perforation  of  the 
left  tympanum  with  a  little  suppuration  of  the  right  ear 
tympanum  and  a  slight  tear  of  the  right  tympanum.  In 
April,  191 5,  the  hearing  was  cured. 


704  TREATMENT  AND  RESULTS 

These  men  had  been  under  fire  several  months,  and  had 
taken  part  in  the  battle  of  the  Marne.  It  was  not  a  question 
of  their  first  baptism  of  fire,  and  in  fact,  each  of  them  had 
been  previously  wounded.  According  to  Roussy,  the  story 
is,  that  the  shell-burst  produces  by  displacement  of  air  tym- 
panic perforation,  and  at  the  same  time  a  violent  nerve 
shock  with  loss  of  consciousness  for  a  few  minutes.  The 
men  come  to,  but  the  ear  lesion,  probably  exaggerated  by  the 
nervous  status  of  its  bearer,  creates  a  complete  bilateral  deaf- 
ness.    This  deafness  produces  an  absolute  hysterical  mutism. 

Re  case  groups  of  war  neurosis,  several  writers  speak  of 
dangers  of  contagion,  but  also  emphasize  the  values  of  con- 
tact of  patients  with  one  another  in  the  securing  of  thera- 
peutic results.  What  Mott  has  termed  the  atmosphere  of 
cure  was  no  doubt  present  in  the  three  instances  of  Roussy 
just  cited.  The  cure  of  one  may  act  heterosuggestively  to 
produce  the  cure  of  a  second,  and  so  on.  Functional  deaf- 
mutes  are  somewhat  refractory  as  a  rule.  H.  Campbell 
states  that  there  is  some  danger  attached  to  allowing  large 
numbers  of  functional  cases  to  consort  together  too  closely. 
He  suggests  making  use  of  small  wards  and  screens,  and  a 
process  of  sorting  out  patients  so  that  they  shall  not  affect 
one  another  injuriously.  Steiner  especially  stresses  the  value 
of  individual  rooms  in  preventing  psychic  infection,  of 
which,  he  says,  the  danger  is  large  in  open  dormitories.  The 
psychic  contagion  is  as  a  rule  that  of  hysterical  seizures  and 
tremors;  but  complaints  about  faulty  hospital  arrange- 
ments are  also  readily  spread.  Steiner  advocates  never 
questioning  a  nervous  patient  concerning  his  troubles  in  the 
presence  of  other  soldiers.  To  reach  60  to  70  patients, 
Steiner  had  one  examining  and  treatment  room.  Roussy's 
institution  at  Salins  in  191 7  had  a  service  limited  to  traumatic 
hysteria,  from  which,  in  three  months'  time,  200  subjects  had 
been  discharged  cured  (see  Boschi). 


TREATMENT  AND  RESULTS  705 


Dysentery:  Milk  diet  persisted  in:  Vomiting,  in- 
continence, inability  to  walk.     Cure  by  persuasion. 


Case  500.     (McDowell,  December,  1916.) 

A  soldier,  25,  a  low  menial  when  war  broke  out,  developed 
"  dysentery  and  gastritis  "  at  the  Dardanelles,  although 
even  before  the  dysentery  his  nerves  had  gone  bad.  He  had 
diarrhoea  and  vomiting,  was  sick  every  day,  found  himself 
unable  to  walk,  and  found  himself  always  wet  with  urine 
dribbling  day  and  night.  Arriving  in  England  and  treated 
in  a  hospital,  he  still  had  vomiting.  He  had  lived  on  milk 
and  custard  and  been  kept  in  bed. 

.  Capt.  McDowell  convinced  the  patient  that  his  legs  were 
not  as  weak  as  he  supposed.  He  was  encouraged  to  walk, 
put  upon  light  diet  and  then  upon  ordinary  diet.  He  be- 
came an  active  worker  in  the  ward,  later  going  for  five- mile 
route  marches.  Two  months  later  he  went  back  to  duty  in 
good  health,  weighing  seven  pounds  more  than  before.  This 
man  was  weakminded  and,  w^hen  his  dysentery  was  cured, 
did  not  dare  to  start  eating  ordinary  food.  He  was  a  victim 
of  hospital  regime.  Individual  attention  would  have  obvi- 
ated much  of  the  subsequent  state. 

Re  vomiting,  see  remarks  under  another  case  of  McDowell 
(Case  495). 

Re  incontinence,  see  Case  384,  of  Guillain  and  Barre. 


7o6  TREATMENT   AND    RESULTS 


Officer  dies  in  convulsions :  Servant  develops  hys- 
terical convulsions,  which  vanish  on  being  ex- 
plained as  such. 


Case  501.     (Hurst,  March,  1917.) 

An  officer  and  his  serv^ant  were  blown  up  by  a  shell.  The 
servant  ran  to  fetch  a  stretcher  for  the  officer,  to  whom  he  was 
much  attached,  but  on  his  return  the  officer  made  a  few 
convulsive  movements  and  died.  Immediately  after,  the 
servant  had  a  fit.  During  the  next  two  months  he  had  eleven 
more.  Hurst  made  a  diagnosis  of  hysterical  fits  resulting 
from  emotion,  explained  his  idea  of  their  origin  and  nature 
to  the  servant,  and  the  convulsions  then  ceased  completely. 

Re  hysterical  convulsions,  see  remarks  under  Case  443. 


Course  of  a  case  with  crises  of  trembling. 


Case  502.     (RoussY,  April,  191 5.) 

A  soldier  in  the  artillery,  who  had  been  in  the  lines  from 
August  as  a  kitchenman,  looking  after  the  food  of  the  first 
line  trenches,  with  which  his  shelter  was  connected  by  com- 
munication trenches,  800  meters  away,  was  on  January  17, 
191 5,  with  three  other  men  placed  in  the  shelter  kitchen  of 
the  trenches  but  a  short  distance  away  from  the  French  ar- 
tillery. The  firing  passed  over  the  heads  of  these  men  but 
they  could  feel  the  windage,  which  obliged  them  to  lie  down 
each  time.  The  evening  of  that  day,  several  hours  after 
firing  had  ceased,  the  kitchenman  had  a  shivering  spell,  with 
trembling  that  lasted  all  night ;  after  which  these  crises  came 
on  every  day.     He  had  finally  to  be  evacuated  to  the  rear. 

According  to  Roussy,  such  patients  always  have  neuro- 
pathic taint  and  a  history  of  previous  crises.  Such  a  patient 
ought  to  be  handled  with  rather  severe  discipline.  In  this 
way,  according  to  Roussy,  the  reappearance  of  a  severe  attack 
of  convulsions  can  be  prevented.  But  these  patients  cannot 
go  back  to  the  front. 

Re  tremors,  see  Cases  224  and  225. 


TREATMENT  AND   RESULTS  707 


Two    cases    of    lameness    cured    by  persuasion: 
Russel. 


Case  503.     (RussEL,  August,  1917.) 

A  man  on  crutches,  paralyzed  completely  in  the  right  leg, 
partially  in  the  left,  developed  paralysis  in  the  right  arm 
from  the  use  of  the  crutch.  There  were  marked  vasomotor 
changes  in  the  right  leg  and  arm  together  with  anesthesia 
to  pinprick.  Assured  that  he  could  move  the  legs  perfectly 
he  said  that  he  had  tried  and  failed.  After  a  persuasive  talk 
in  private  he  began  to  use  the  arm,  and  to  walk  perfectly. 
It  seems  that  in  the  trenches  he  had  a  sharp  pain  in  the 
right  knee,  after  which  he  did  not  use  the  leg  and  it  gradually 
became  more  and  more  useless.  It  had  been  paralyzed  for 
three  months.  The  reason  he  did  not  use  this  leg  was  not 
on  his  own  account,  but  on  account  of  his  mother  at  home. 
He  seemed  really  grateful  for  the  cure. 

Case  504.     (RussEL,  August,  191 7.) 

A  sergeant  in  hospital  for  a  year  for  shell-shock  still  had 
a  marked  shaking  of  the  right  leg  whenever  he  raised  it  from 
the  ground.  He  walked  in  leaning  on  a  silver  headed  cane. 
The  functional  nature  of  his  shaking  was  explained  to  him 
by  Russel,  whereupon  he  walked  out  normally  saying  he 
could  do  without  his  cane.  Russel  suggested  that  crutches 
and  sticks  thus  given  up  were  often  donated  to  the  shrine. 
The  sergeant  whose  cane  must  have  cost  at  least  three  pounds 
beat  a  hasty  retreat  carrying  the  cane  in  front  of  him. 

Re  Russel's  general  point  of  view  concerning  malingerers 
and  psychogenic  cases,  see  under  Case  458. 


708  TREATMENT  AND  RESULTS 


Hard  patrol  work:  Delirium;  head  tremor  aug- 
mented by  excitement:  Virtual  recovery  on  ban- 
daging neck,  isolation,  open  air,  to-and-fro  transfers 
to  mental  and  nervous  wards. 


Case  505.     (BiNSWANGER,  July,  1915.) 

A  metal  moulder  in  civil  life,  29,  in  military  service  1907 
to  1909  (no  hereditary  taint,  moderately  good  scholar), 
became  unconscious  for  a  half  hour  after  taking  a  cold  drink 
following  a  somewhat  long  practice  march,  at  some  time  dur- 
ing his  first  year  of  military  service. 

He  was  in  several  skirmishes  in  Belgium  and  Northern 
France  early  in  the  war,  being  once  surrounded  in  patrol 
work  (November  11)  by  Turcoes  and  Zouaves.  There  was 
a  lively  exchange  of  shots,  in  the  course  of  which  five  of 
the  eight  men  on  patrol  fell.  The  three  survivors  hid  them- 
selves for  three  days  in  a  quarry,  and  on  the  fourth  were 
found  by  the  advancing  troops,  and  immediately  went  into 
battle. 

But  during  a  pause  while  on  the  point  of  taking  cofifee,  the 
man  suddenly  fell  sick,  tried  to  carry  on,  but  lost  conscious- 
ness and  apparently  remained  unconscious  for  about  three- 
quarters  of  an  hour.  It  seems  that  he  raved  and  shouted 
and  tried  to  bite  his  fingers,  being  held  with  great  difficulty 
by  several  comrades.  He  was  removed  to  a  dressing-station 
three  km.  distant. 

At  the  dressing-station,  his  head  began  to  shake,  although 
he  was  unaware  of  this  until  his  attention  was  called  to  it  by 
his  comrades.  He  said  that  he  felt  restless  and  that  his  head 
ached  almost  continually.  He  was  carried  to  the  reserve 
hospital,  and  from  thence,  December  9,  1914,  to  the  nerve 
hospital  at  Jena,  where  he  was  unaware  of  the  shaking  of  his 
head  (which  had  now  lasted  for  three  weeks),  and  said  that 
he  felt  a  thick  fog  in  his  head  (to  say  nothing  of  headaches), 
and  was  only  free  and  clear  in  his  head  while  standing  in  the 
open  air. 


TREATMENT  AND  RESULTS  709 

His  sleep  was  restless  and  poor;  there  were  war  dreams  al- 
most every  night.  In  the  process  of  getting  to  sleep,  his 
arms  and  legs  frequently  twitched.  He  would  soon  tire  and 
feel  weak.  Also  since  his  dangerous  experience,  he  had 
noticed  a  change  in  his  speech:  always  fluent  before,  it  was 
now  hard  for  him  to  speak  because  one  had  to  exert  one's 
head  so  much  in  speaking. 

This  head  tremor  was  in  fact  the  most  marked  symptom 
of  his  illness.  It  would  increase  on  every  active  motion  of 
the  head,  but  ceased  almost  entirely  when  attention  was  di- 
verted.    The  head  would  then  be  held  bent   to   the  right. 

During  emotional  excitement,  the  shaking  spasm  would 
spread  over  the  entire  upper  part  of  the  body,  but  would 
remain  more  severe  upon  the  right  than  upon  the  left  side. 
The  forearms  would  fall  into  a  lively  shaking  movement  of 
pronation  and  supination.  The  hands  and  fingers  would  be 
attacked  by  a  less  marked  tremor.  After  calm  had  set  in, 
a  fine  tremor  of  the  right  hand  would  remain  plainly  notice- 
able. The  musculature  of  facial  expression  would  frequently 
fall  into  spasmodic  movement,  the  left  corner  of  the  mouth 
twitching,  the  lips  set  for  whistling,  or  the  upper  lip  making 
movements  as  if  snuffing  spasmodically. 

Physically  the  man  was  of  medium  height,  strongly  built, 
with  adherent  lobules,  and  a  somewhat  pointed  skull.  The 
teeth  were  defective  and  irregularly  placed.  Both  deep  and 
skin  reflexes  were  increased.  Marked  dermatographia  and 
mechanical  excitability  of  the  muscles:  periosteal  reflexes 
strongly  developed;  numerous  pressure  points  in  the  head. 
The  right  temple  and  back  of  the  head  were  painful  on  per- 
cussion. The  patient  showed  no  disturbance  in  touch  and 
pain  sensibility.  Outstretched  tongue  showed  marked  fibril- 
lary twitching;  speech  was  difficult,  being  slow,  awkward, 
stumbling,  and  sometimes  hesitating  (suggesting  the  speech 
of  general  paresis).  At  other  times,  the  speech  was  of  a 
peculiar  sighing,  tremulous  nature,  reminding  one  of  the 
speech  of  children  complaining  or  asking  for  pity.  Rest 
was  secured  by  injections  of  salt  solution.  A  few  days  later, 
the  treatment  was  continued  by  a  bandage  about  the  neck. 
After  this  the  tremor  grew  slighter  and  would  even  remain 


710  TREATMENT  AND  RESULTS 

absent  for  some  hours.  The  patient  was  told  to  rest  in  bed 
and  not  to  speak  much;  being  "  seriously  ill,"  he  was  kept 
alone.  He  was  often  irritated,  querulous,  and  subject  to 
outbursts  of  profanity.  He  took  food  well  and  slept  well,  re- 
ceiving sodium  bicarbonate. 

The  bandage  was  changed  after  five  days.  The  tremor  was 
very  marked.  The  patient  was  furious  because  visitors  were 
refused  to  him.  He  was  especially  angry  with  his  nearest 
relatives  and  his  betrothed,  and  wrote  defiant  letters  to  all 
of  them.  He  became  one  of  the  most  troublesome  patients 
in  the  psychiatric  division  of  the  hospital.  He  complained 
sometimes  of  anxiety  and  feelings  of  unrest.  He  received 
treatment  by  pantopon.  He  continued  to  be  a  very  disa- 
greeable patient,  feeling  himself  opposed  and  not  properly 
considered.  He  thought  himself  seriously  ill,  behaved  much 
like  a  spoiled  child,  and  was  of  the  opinion  that  he  would  not 
get  well  in  the  hospital  because  they  were  grieving  him  so. 
His  appetite  became  bad;  he  complained  of  pains  in  the 
loins  and  of  rheumatism  in  the  legs.  A  cord  was  found 
hidden  in  the  bed.  The  patient  expressed  suicidal  thoughts 
at  various  times. 

At  the  beginning  of  January  there  was  marked  improvement. 
The  headshaking  ceased  almost  entirely;  the  patient  walked 
in  the  garden  some  hours  daily.  However,  in  the  middle  of 
January,  on  refusal  of  furlough,  the  head-shaking  began  again 
markedly.  At  his  request  a  bandage  was  placed  on  the  head 
again  for  a  few  days.  He  seemed  emotionally  very  tender; 
his  head  would  shake  at  the  sight  of  a  dead  rabbit. 

He  was  transferred  to  the  nerve  division  of  the  psychiatric 
clinic  at  the  end  of  January.  He  had  recently  begun  to 
complain  of  flickering  before  the  eyes.  The  ophthalmolo- 
gists established  an  existence  of  a  choroiditis  disseminata. 
The  eye  examination  had  a  markedly  depressing  effect  upon 
the  patient,  and  the  shaking  spasm  of  the  head  appeared 
again.  Upon  being  told  that  he  would  have  to  be  sent  back 
to  the  psychiatric  section  of  the  clinic,  the  shaking  immedi- 
ately disappeared  (24  hours  after  it  had  begun). 

Thereafter  slow  improvement  followed.  He  stayed  in  the 
open  a  great  deal  and  walked.     March  2,  he  showed  a  ve- 


TREATMENT  AND  RESULTS  7II 

hement  outburst  of  anger,  quarreling  and  using  violence 
with  a  comrade.  He  was  brought  back  to  the  psychiatric 
section,  and  in  transit  had  a  severe  hysterical  attack  with 
unconsciousness,  crying  fits,  and  stepping  movements  of  the 
extremities.  He  was  promptly  taken  to  a  section  for  those 
seriously  ill.  The  next  day,  upon  his  assurance  that  he  could 
control  himself,  he  was  put  in  a  more  quiet  division.  He 
began  to  take  part  in  gymnastic  exercises,  worked  as  a  coach- 
man, and  then  as  an  experiment  was  sent  to  a  gentleman's 
estate  for  recreation.  At  last  accounts  he  was  feeling  well 
except  that  he  occasionally  had  headaches  during  work.  He 
could  not  work  so  hard  as  before  on  account  of  the  rapid  onset 
of  fatigue,  especially  when  working  in  the  sun.  The  head- 
shaking  recurred  but  seldom  and  lasted  for  a  few  hours  only 
when  the  patient  became  angry  or  when  there  was  much  noise 
about. 


712  TREATMENT   AND   RESULTS 


Rationalization    of    war   memories:    Returned   to 
duty. 


Case  506.     (Rivers,  February,  1918.) 

A  young  English  officer  was  wounded  just  as  he  was  ex- 
tricating himself  from  burial  in  a  mass  of  earth.  He  became 
nervous  and  sleepless  and  lost  his  appetite.  After  the 
wound  had  healed,  he  was  sent  home  on  leave,  which  had  to 
be  extended  as  he  got  worse.  An  out-patient  in  London  for 
a  time,  he  was  finally  sent  to  a  convalescent  home,  still 
troubled  with  insomnia,  battle  dreams  and  concern  about  his 
recovery.  He  made  light  of  his  condition  and  was  on  the 
point  of  being  returned  to  duty  by  the  medical  board,  when 
his  sleeplessness  led  to  his  being  sent  to  Craighlochart  War 
Hospital. 

He  could  not  sleep  without  a  light  in  the  room,  else  every 
sound  attracted  his  attention.  He  tried  hard  all  day  long  to 
banish  all  unpleasant  and  disturbing  thoughts,  but  at  night 
it  took  him  a  long  time  to  get  to  sleep  and  then  came  vivid 
dreams  of  warfare.  He  did  not,  himself,  feel  that  he  could 
ever  forget  the  war  scenes. 

Rivers,  in  general  believing  that  the  attempt  to  banish 
such  experiences  absolutely  from  the  mind  is  poor  psycho- 
therapy, narrated  his  views  to  the  patient  Rivers  advised 
him  no  longer  to  try  to  banish  the  memories,  but  to  try  to 
transform  them  into  tolerable,  if  not  pleasant,  companions. 
The  war  experiences  and  anxieties  were  talked  over.  That 
night  the  man  had  the  best  night  he  had  had  for  five  months, 
and  during  the  following  week  the  sleeplessness  was  no  longer 
so  painful  and  distressing.  If  unpleasant  thoughts  came, 
they  had  to  do  rather  with  home  life  than  with  the  war. 
General  health  improved;  insomnia  diminished.  He  was  at 
last  able  to  return  to  duty. 


TREATMENT   AND   RESULTS  713 


Rationalization  of  war  memories. 


Case  507.     (Rivers,  February,  1918.) 

An  English  officer  was  buried  by  shell  explosion  and  de- 
veloped severe  headache,  vomiting  and  disorder  of  micturition, 
yet  remained  on  duty  for  more  than  two  months.  Collapse 
came  when  he  went  out  to  seek  a  fellow  officer  and  found  the 
body  blown  to  pieces,  with  head  and  limbs  severed  from 
the  trunk.  This  vision  haunted  him  in  dreams.  Some- 
times the  officer  appeared  as  on  the  battlefield;  again  as 
leprous.  The  officer  would  come  nearer  and  nearer  in  the 
dream,  until  the  patient  woke  pouring  with  sweat  and  in 
utmost  terror.  Accordingly,  he  was  afraid  to  go  to  sleep, 
and  spent  all  day  thinking  painfully  about  the  night  to  come. 
Advice  to  keep  all  thoughts  of  war  out  of  mind  merely  brought 
the  memories  in  sleep  upon  him  with  redoubled  force  and 
horror. 

Rivers'  therapy  was  to  draw  attention  to  the  fact  that  the 
terrible  mangling  proved  conclusively  that  the  officer  had 
been  killed  outright  and  without  pain.  The  officer  said  he 
would  now  no  longer  attempt  to  banish  the  thoughts  and 
memories  of  his  friend,  but  would  concentrate  on  the  pain  and 
suffering  his  friend  had  been  spared.  No  dreams  at  all  came 
for  several  nights,  but  one  night  In  his  dream  he  went  out 
into  No-Man's-Land  and  saw  the  mangled  body,  but  without 
horror.  He  knelt  down,  as  he  had  in  the  original  experience, 
and  woke  as  he  was  taking  off  the  Sam  Browne  belt  to  send  to 
the  relatives.  A  few  nights  later  came  another  dream  in 
which  he  talked  with  his  friend.  There  was  but  one  more 
dream  in  which  horror  occurred. 


714  TREATMENT  AND  RESULTS 


Rationalization  of  war  memories:  Eventually  un- 
fitted for  military  service. 


Case  508.     (Rivers,  February,  191 8.) 

A  young  English  officer,  after  doing  well  for  a  period,  was 
rendered  unconscious  by  shell  explosion.  The  first  thing  he 
remembered  was  being  led  by  his  servant  towards  his  base, 
thoroughly  broken  down.  He  had  headaches,  sleeplessness, 
war  dreams  and  spells  of  terrible  depression  appearing  with 
absolute  suddenness,  unlike  ordinary  "  blues."  For  ten  days 
in  hospital  no  such  attack  appeared,  but  one  evening  he  came 
to  Rivers  pale  and  anxious.  A  few  minutes  before,  he  had 
been  writing  a  letter  in  his  usual  mood,  when  this  causeless 
depression  came  on.  In  the  afternoon  he  had  walked  about 
on  some  neighboring  hills.  The  letter  dealt  with  no  de- 
pressing matter.  In  ten  minutes  the  depression  vanished. 
Nine  days  later  another  came  as  he  was  standing  idly  looking 
out  of  a  window.  The  attack  lasted  for  several  hours,  as  no 
physician  was  present  to  meet  the  issue.  If  he  had  had  a 
revolver  he  would  have  shot  himself. 

Rivers  was  inclined  to  interpret  these  gusts  of  depression 
as  due  to  a  forgotten  but  active  experience.  As  there  was 
no  definite  tendency  to  dissociation,  Rivers  hesitated  to 
plunge  in  with  the  hypnotic  method,  nothing  short  of  which, 
however,  served  to  recall  the  incident.  The  man  was  gravely 
apprehensive  about  fitness  for  further  service,  and  was  re- 
pressing his  fear,  as  he  thought  it  either  was  cowardice  or 
would  be  called  cowardice.  The  patient,  by  his  discussions 
with  Rivers,  had  already  become  familiar  with  the  idea  that 
the  gusts  of  depression  might  be  due  to  a  submerged  expe- 
rience. Perhaps,  however,  there  had  been  no  experience, 
and  the  patient  was  advised  that  possibly  the  thing  repressed 
was  the  idea  about  fitness  for  service.  Accordingly,  the 
patient  agreed  to  face  the  situation.  One  transient  attack  of 
morbid  depression  occurred,  after  an  operation.  Then  the 
man  fell  into  a  state  of  anxiety  neurosis  such  that  he  was 
passed  by  a  medical  board  as  unfit  for  military  service. 


TREATMENT  AND   RESULTS  715 


Rationalization    of    war  memories :    Commission 
relinquished. 


Case  509.     (Rivers,  February,  1918.) 

An  oldish  English  officer  lost  consciousness  while  looking 
at  the  havoc  wrought  by  shell  explosion.  Probably  there  was 
a  second  shell  that  sent  him  off.  He  was  eventually  admitted 
to  an  English  hospital  with  paresis  and  anesthesia  of  legs, 
severe  headache,  sleeplessness  and  terrifying  dreams.  Hyp- 
notic drugs  and  advice  neither  to  read  nor  to  talk  about  the 
war  were  the  measures  adopted  and  after  two  months  in 
hospital  he  was  given  three  months  leave.  He  buried  him- 
self in  the  heart  of  the  country,  away  from  relatives,  with 
aspirin  and  bromides.  He  began  to  sleep  better  and  had 
less  headache.  When  the  president  of  the  medical  board 
asked  a  question  about  trenches  at  the  end  of  his  period  of 
leave,  however,  he  broke  down  and  wept.  He  again  re- 
paired to  the  country  for  two  months'  leave,  for  the  chosen 
treatment  by  isolation  and  repression. 

An  order  was  then  given  that  all  officers  must  be  either 
in  hospital  or  on  duty.  He  was  sent  to  an  inland  watering 
place  and  treated  by  baths,  electricity  and  massage,  where- 
upon he  rapidly  became  worse,  especially  as  to  sleep.  He 
was  transferred  to  Craiglochart  in  an  emaciated  state,  with 
an  expression  of  anxiety  and  dread,  paresis  of  legs,  sleep- 
lessness and  war  dreams. 

He  was  now  advised  to  give  up  repressing,  to  read  and 
talk  a  little  about  the  war,  and  to  accustom  himself  to  think- 
ing about  war  experiences.  He  did  this  but  half-heartedly, 
as  he  thought  the  ideal  treatment  was  what  he  had  so  long 
followed.  Nevertheless,  he  got  distinctly  better  and  the  con- 
tent of  the  war  dreams  was  altered  to  home  scenes.  He  was 
still  loath  to  acknowledge  his  improvement  and  thought  that 
he  would  have  recovered  if  he  had  not  been  taken  from  his 
retreat  and  sent  to  hospital.  As  it  was  obvious  that  he 
would  be  of  no  further  use  in  the  army,  he  was  allowed  to 
relinquish  his  commission. 


71 6  TREATMENT   AND   RESULTS 


Rationalization  of  war  memories,  without  redeem- 
ing feature  as  nucleus. 


Case  510.     (Rivers,  February,  191 8.) 

An  English  officer  was  flung  by  shell  explosion  so  that  his 
face  struck  the  ruptured  and  distended  abdomen  of  a  dead 
German.  The  officer  did  not  immediately  lose  conscious- 
ness and  got  distinct  impressions  of  taste  and  smell  and  an 
idea  of  their  source  After  a  period  of  unconsciousness  he 
came  to,  vomiting  and  much  shaken.  He  carried  on  several 
days,  still  troubled  by  vomiting  and  haunted  by  taste  and 
smell  images.  Several  months  later  he  was  observed  by 
Rivers  suffering  from  horrible  dreams,  in  which  the  battle 
experience  was  faithfully  reproduced.  He  got  no  relief  ex- 
cept when  he  went  into  the  country,  far  from  every  sugges- 
tion of  war.  Rivers'  psychotherapeutic  plan  of  finding  a 
redeeming  feature  in  the  experience,  upon  which  the  patient 
might  concentrate,  failed  because  there  was  no  redeeming 
feature.  Accordingly,  it  was  thought  best  that  the  man 
should  leave  the  army  and  seek  the  conditions  that  had 
given  him  slight  relief. 

Re  psychoanalysis  and  its  modifications,  see  remarks  under 
Case  496,  under  which  several  favorable  opinions  were  men- 
tioned. Boschi  in  his  report  on  French  conditions  gives  no 
reference  concerning  psychoanalysis  or  hypnosis.  Bruce 
has  found  blended  with  the  war  dreams  many  episodes  quite 
alien  to  the  war,  and  considers  that  the  patient's  ante-bellum 
history  is  of  importance,  since  ante-bellum  emotions  may 
be  revivified  by  the  war.  Craig  states  that  he  has  not  been 
impressed  favorably  by  the  results  of  psychoanalytic  treat- 
ment. Arinstein  from  Russian  experience  gives  preference 
to  Dubois'  psychotherapy  over  hypnosis  and  psychoanaly- 
sis. Nonne  states  that  the  data  of  the  war  prove  that 
hysteria  is  neither  a  degenerative  disease  according  to  classi- 
cal theory,  nor  a  disease  based  upon  Freudian  principles. 


TREATMENT  AND   RESULTS  717 


Post  rhemnatic  ''paraplegia  "  (or  abulia?)  cured  by 
removal  of  crutches,  after  question  of  discharge 
''unfit "  had  been  raised. 


Case  511.     (Veale,  November,  1917.) 

A  soldier,  23,  had  fever  with  swelling  of  several  joints 
and  temperature  in  191 5,  and  was  furloughed  to  England. 
He  complained  of  pains  in  the  limbs  and  shortness  of  breath, 
and  was  put  in  hospital.  As  he  did  not  improve,  he  was  sent 
to  a  special  hospital  for  baths  and  electricity.  There  he 
remained  from  August,  1915,  to  March,  1916,  with  D'Arsonval 
baths,  cataphoresis,  electric  treatment  and  massage. 

He  was  now  sent  to  the  second  Northern  General  Hospital 
to  see  whether  he  should  be  discharged  permanently  unfit. 
Here  he  shuffled  along  on  two  crutches,  very  tremulous,  and 
sweating,  and  suffering  from  palpitation  on  exertion.  He 
wanted  to  take  poison  if  he  could  not  be  cured. 

The  crutches  were  taken  away.  He  was  asked  to  walk  up 
and  down.  He  had  to  be  supported  at  first  and  fell  several 
times.  The  exercises  were  continued.  Massage  and  drug- 
ging were  stopped.  The  next  day  he  was  able  to  stand 
alone.  In  twenty-four  hours  he  walked  by  himself.  The 
other  patients  in  the  ward  encouraged  him  on  account  of  the 
genuine  exertions  he  was  making  to  get  well.  April  7,  he 
returned  to  duty,  smart  and  well  set  up. 

Babinski  and  Froment  always  give  the  suspected  subject 
the  benefit  of  the  doubt,  never  uttering  the  word  simulation 
in  the  presence  of  the  soldier,  and  proceed  to  psychotherapy ; 
for  psychotherapy  will  act  to  cure  simulation  or  exaggeration 
just  as  it  acts  to  cure  hysteria.  They  say  that  in  their  expe- 
rience, all  these  disorders  of  doubtful  nature  —  that  is,  that 
lie  diagnostically  between  hysteria,  exaggeration,  and  simu- 
lation —  are  as  a  rule  cured  by  resort  to  psychotherapy  pro- 
vided that  the  due  amount  of  energy,  tact,  and  perseverance 
is  employed.  See  also  remarks  under  Case  453.  Veale's 
case  (511)  never  showed  mauvaise  volonte,  and  nothing  more 
than  aboulia. 


7l8  TREATMENT   AND    RESULTS 


**  Trench  foot,"  '*  neuritis,"  a  year  of  astasia-abasia 
or  at  least  of  complaint  of  inability  to  stand  or  walk. 
Treatment  by  a  *'  cruel  though  justifiable  "  process. 


Case  512.     (Veale,  November,  191 7.) 

A  regular  army  man,  38,  well  built  and  muscular,  in 
Flanders  the  first  winter,  returned  to  England  in  January, 
1915,  with  "trench  foot."  "Neuritis"  then  developed,  with 
loss  of  power  to  walk.  Baths,  electricity,  massage,  sym- 
pathetic wheeling  about  in  a  chair  by  women,  all  failed. 

January  11,  1916,  he  still  complained  of  Inability  to  walk 
or  stand.  The  reflexes  were  exaggerated.  He  was  able  to 
get  into  a  wheel  chair  from  bed  by  jerks,  associated  with 
palpitation,  tremors,  flushing  and  sweating. 

He  was  told  that  he  had  now  recovered  from  the  neuritis. 
Crutches,  sticks  and  wheelchair  were  removed.  He  flopped 
about  and  then  lay  on  the  bed  exhausted.  In  a  few  days  he 
began  to  shuffle  about  and  was  put  on  the  stationary  bicycle. 
January  29,  he  left  the  hospital  well,  remarking  that  though 
the  treatment  at  first  seemed  cruel,  It  was  fully  justified. 

Re  genuine  polyneuritis,  Mann  gives  German  experience 
regarding  neuritis  as  somewhat  frequent  and  affecting  a 
special  form  which  he  terms  polyneuritis  neurasthenica.  He 
states  that  the  commonest  instances  of  mononeuritis  devel- 
oping in  the  war  are  the  sciatic  and  trigeminal.  The  neuritis 
often  outlasts  the  other  symptoms.  The  treatment  was  rest, 
tepid  baths,  and  electricity.  Naturally,  alcohol  and  syphilis 
must  be  excluded  in  the  diagnosis. 

Nonne  also  described  non-alcoholic,  non-syphilitic,  and 
non-infectious  polyneuritis  in  neurasthenics,  which  he,  how- 
ever, finds  most  common  in  the  ulnar,  median,  radial,  an- 
terior crural  and  posterior  tibial  nerves. 

Re  "spa"  treatment.  Turner  thinks  there  may  be  easily 
too  much  massage,  electricity,  bathing.  He  prefers  segrega- 
tion in  special  hospitals  to  "spa"  measures  in  general  hos- 
pitals, prefers  occupation  to  rest,  and  calls  attention  to  the 
stimulating  value  of  the  gratuity  to  be  paid  on  leaving  the 
hospital. 


TREATMENT  AND  RESULTS  719 


Shell-shock  paraplegia:  Treatment  by  bed,  ciga- 
rettes and  chocolates  altered  to  isolation,  no 
tobacco,  no  visitors,  faradization.     Recovery. 


Case  513.     (Buzzard,  December,  1916.) 

Early  in  the  war,  a  lad,  19,  was  blown  up  by  a  shell.  He 
was  sent  home  paralyzed  from  waist  down,  and  was  seen  by 
Capt.  Buzzard  after  he  had  spent  ten  months  in  various 
hospitals,  "carefully  nursed,  on  the  water  bed,  constantl^^ 
using  a  bed  urinal,  smoking  innumerable  cigarettes,  and  eat- 
ing countless  chocolates."  He  could  not  move  his  legs. 
They  were  wasted  and  flaccid.  The  knee-jerks  could  be  got 
with  difficulty.  Plantar  reflexes  flexor.  Complete  anesthesia 
from  umbilicus  downwards,  but  preservation  of  abdominal 
reflexes.  The  navel  did  not  shift  downwards  when  the 
patient  attempted  to  sit  up.  The  incontinence  was  not  real ; 
urine  was  passed  into  the  urinal  at  appropriate  intervals. 

Buzzard  directed  treatment  "not  to  his  spinal  cord  but  to 
his  mind;  isolation;  the  stoppage  of  tobacco  and  all  visits; 
the  assurance  that  he  would  rapidly  get  well,  together  with 
some  suggestive  faradization  of  his  legs."  This  brought 
about  a  cure  in  a  very  short  period.  The  atrophied  legs 
eventually  grew  strong  enough  to  walk. 

Re  cigarettes  in  Shell-shock,  Mott  decries  the  over-liberal 
gifts  of  cigarettes  that  induced  cigarette  habits  in  both 
officers  and  men.  Of  course,  the  cigarettes  are  still  more 
detrimental  to  cases  of  soldier's  heart  than  to  other  cases  of 
neurosis.  Mott  remarks  how  over-frequent  are  the  social 
tea-parties,  joy  rides  and  drives  given  by  well-meaning  ladies 
for  the   "poor  dears,"   actually  perpetuating  neuroses. 

Re  atrophy,  Babinski  and  Froment  again  bring  up  the 
question  whether  muscular  atrophy  can  be  brought  about 
by  a  hysterical  motor  disorder.  In  point  of  fact,  Charcot 
and  Babinski  were  the  first  to  describe  the  true  hysterical 
amyotrophy,  but  this  hysterical  amyotrophy  is  exceptional 
in  hysterical  paralysis,  and  is  slight  when  it  occurs. 


720  TREATMENT  AND   RESULTS 


Shell-shock  blindness,  mutism,  deafness:  Blind- 
ness spontaneously  vanished,  24  hours.  Mutism, 
2-3  months.    Deafness  cured  by  '*  small  operation." 


Case  514.     (Hurst,  September,  1917.) 

A  lance  corporal,  26,  became  blind,  deaf  and  dumb,  though 
without  losing  consciousness,  when  blown  up  by  a  shell, 
August  29,  191 6.  His  sight  returned  next  day.  On  reaching 
England  he  talked  in  his  sleep.  Encouragement,  electricity, 
etherization  failed  to  effect  improvement.  One  night  in 
November  he  woke  up  and  asked  the  sister  for  a  drink; 
thereafter  he  talked  normally. 

Seven  months  after  the  shell  explosion  he  was  transferred 
to  the  neurological  section  at  Netley,  March  21,  191 7.  Deaf 
to  air  and  bone  conduction,  a  loud  noise  behind  him  caused 
a  slight  tremor  of  hands,  with  blinking  and  dilatation  of  pupils; 
but  further  stimuli  of  the  same  sort  failed  to  produce  such 
reactions.  Normal  nystagmus  and  giddiness  on  functional 
tests  of  vestibular  nerve  and  canals.  The  Internal  ear  was 
then  probably  free  from  organic  changes.  Since  shell-shock 
mutism  is  always  hysterical,  It  was  probable  that  the  deaf- 
ness was  hysterical.  Under  hypnosis  (staring  at  lines  for 
fifteen  seconds)  he  showed  no  change.  During  natural 
sleep,  also,  a  shout  of  "Fire"  and  metallic  noises  failed  to 
wake  the  patient  or  to  produce  contraction  of  eyelids.  Elec- 
tric suggestion  (despite  the  patient's  belief  In  electricity)  and 
reeducation  failed. 

April  16,  he  was  told  that  a  small  operation  would  have  to 
be  done  April  20.  To  this  he  readily  consented.  Two  small 
incisions  were  made  behind  the  ear  under  light  ether  and 
suture  was  Inserted.  A  loud  noise  was  made  during  the 
"operation";  he  heard  this  noise  and  jumped  from  the 
table.  To  his  intense  delight  normal  hearing  returned  In 
a  few  minutes.  Next  day  hearing  was  tested  and  found 
normal  to  air  and  bone  conduction.  He  was  discharged  to 
duty  three  weeks  later  and  on  his  way  to  France,  June  29, 
demonstrated  his  normal  hearing  to  the  physicians. 


TREATMENT  AND  RESULTS  721 


Deafness :  cure  by  stimulating  vestibular  apparatus. 


Case  515.     (O'M ALLEY,  May,  1916.) 

A  private,  20  years  of  age,  lost  speech  and  hearing  after 
the  battle  of  Neuve  Chapelle.  Eight  days  later  he  came 
under  the  care  of  the  laryngologist  in  a  very  excited  state, 
pointing  to  lips  and  ears  and  carrying  a  note  with  informa- 
tion concerning  his  deaf  mutism. 

Dr.  O'Malley  wrote  on  a  piece  of  paper  that  he  would  re- 
store the  patient's  speech  and  hearing.  Dr.  O'Malley  then 
used  the  mirror  until  the  point  of  retching,  and  wrote,  "You 
can  speak  now;  count  up  to  ten  loudly."     He  did. 

Dr.  O'Malley  next  used  the  cold  water  douche  to  the  right 
ear  to  the  point  of  giddiness,  then  shouting  through  a  speak- 
ing-tube (see  description  below).  The  patient  then  found 
he  could  hear  and  the  tears  streamed  down  his  face.  There- 
after he  was  able  to  converse  freely.     Dr.  O'Malley  writes: 

The  treatment  of  functional  deafness  consists  in  ex- 
citing the  vestibular  apparatus  as  follows.  Cold  or  hot 
water  is  allowed  to  flow  in  a  steady  stream  into  and  out 
of  the  external  auditory  meatus  by  means  of  a  tube 
attached  to  a  receptacle  placed  about  one  and  a  half  to 
two  feet  above  the  patient's  head  and  continued  until 
he  becomes  very  giddy  and  an  active  nystagmus  is  pro- 
duced. A  speaking-tube  three  feet  long  is  then  used 
by  placing  the  ear-piece  in  the  ear  so  treated,  and  the 
surgeon  shouts  into  the  mouth-piece  the  assertion, 
"You  hear  now,"  and  the  answer,  "Yes"  comes 
promptly.  The  tube  is  now  dropped  and  a  conversa- 
tion held  as  if  no  deafness  ever  existed.  So  far  I  have 
found  the  treatment  of  one  ear  sufficient.  The  patient  is 
usually  very  emotional,  as  the  disturbed  vestibular  func- 
tion, which  in  these  cases  responds  easily  and  markedly, 
causes  him  to  feel  as  uncomfortable  as  a  bad  sailor  on  a 
stormy  voyage.  This  feeling,  however,  rapidly  gives 
way  to  one  of  pleasure  at  the  return  of  his  hearing. 
Where  functional  deafness  and  mutism  co-exist  it  does 
not  appear  to  be  material  which  is  treated  first.  In  two 
cases  of  this  kind  under  my  care  I  treated  the  loss  of 
voice  first. 


722  TREATMENT  AND   RESULTS 


Bullet  through  mouth :  Hysterical  mutism.     Treat- 
ment by  operative  manipulation. 


Case  516.     (MoRESTiN,  January,  1915.) 

A  Colonial  infantryman,  32,  was  wounded  December  17, 

1 9 14,  at  the  Boisselle,  being  struck  by  a  bullet  which  entered 
on  the  right  side  in  the  upper  part  of  the  neck  and  came  out 
behind  the  left  side  of  the  mouth,  having  traversed  the 
tongue,  broken  two  teeth,  and  caused  a  good  deal  of  hem- 
orrhage by  mouth.  The  patient  felt  his  tongue  swell,  and 
from  this  time  on  he  could  not  pronounce  a  word.  He  was 
sent  to  the  ambulance,  then  to  Alien,  then  to  Saint  Germain, 
and  finally  to  Morestin's  surgical  service.  With  wounds  by 
this  time  healed,  the  patient  found  it  hard  to  open  his  mouth. 
There  was  no  trace  of  fracture  of  the  lower  jaw.  The  tongue 
could  be  only  incompletely  examined.  The  man  swallowed 
liquids  easily  but  could  take  no  solid  food.  He  tried  hard  to 
speak,  made  pantomime  movements,  grew  emotional  and 
lachrymose. 

On  the  whole,  however,  it  seemed  that  his  inability  to 
articulate  sound  could  not  be  due  directly  to  the  lesion. 
There  must  be  either  simulation  or  hysteria.  For  four  days 
he  was  attentively  watched,  and  not  once  did  he  pronounce  a 
word.  He  grew  more  and  more  stricken  and  humiliated 
by  his  plight.  Rigorous  diet  did  not  cause  his  mutism  to 
cease.  Isolation  and  ennui  did  not  decide  him  to  talk.  Ac- 
cordingly, it  was  announced,  in  the  man's  hearing,  that  an 
operation  was   to   be   done   to   restore  speech.     January  9, 

19 1 5,  his  face  was  copiously  washed  with  alcohol  and  ether. 
Cocaine  was  injected  to  secure  anesthesia  and  resolution  of 
the  muscles  of  mastication.  Six  c.c.  of  a  i-ioo  solution  on 
each  side.  Shortly  the  surgeon  began  to  open  the  jaws, 
against  decreasing  resistance.  The  tongue,  which  was  not 
spastic,  was  seized  with  a  tractor  and  rhythmic  movements 
were  executed  with  it.  After  a  few  of  these  movements,  joy 
was  painted  on  the  features  of  the  patient.  He  said  that  he 
wanted  to  speak  and  that  he  was  about  to  speak.     He  shook 


TREATMENT  AND   RESULTS  723 

the  surgeon's  hands  effusively  and  said,  "Merci."  Although 
the  first  words  came  hard,  little  by  little  speech  became  free 
and  a  perfectly  sincere  elation  at  having  recovered  speech 
set  in. 

This  man  was  neuropathic,  having  always  been  a  rather 
strange,  irritable  and  restless  person,  and  given  to  nervous 
crises  in  anger,  in  which  he  lost  consciousness  entirely. 

Re  pseudo  operations  as  forms  of  disguised  persuasion, 
almost  countless  methods  have  been  used.  See  Cases  514, 
515*  518,  519,  especially  521,  560,  561.  Sham  injections 
under  ethyl  chloride  have  been  made  (Goldstein).  See  also 
under  Case  484,  re  continuous  bath,  and  under  Case  488,  re 
lumbar  puncture.  Very  close  to  these  methods  are  the 
methods  of  torpillage  of  Vincent  and  the  methods  employed 
by  Yealland  in  England  and  Kaufmann  in  Germany.  See 
under  Cases  574,  563,  and  564,  and  570. 

Leri  quotes  Babinski  as  saying,  "We  cannot  fight  hysteria 
in  trench  warfare;   manoeuvres  are  necessary." 

Re  treatment  of  mutism,  Chavigny  remarks  that  the 
principle  of  treatment  for  mutism  is  quite  different  from 
the  principles  of  treatment  of  paralysis.  The  reeducation 
of  mutism  Is  psychic.  Chavigny  claims  probably  absolute 
success  in  the  treatment  of  mutism  through  faradism  to  the 
larynx  region  simultaneously  with  a  signal  given  to  the 
patient  to  make  an  effort  to  pronounce  the  letter  A.  Garel 
modifies  the  treatment  (In  case  the  faradic  apparatus  Is  not 
at  hand),  by  a  vigorous  and  sudden  blow  to  the  patient's 
epigastrium  simultaneously  with  the  patient's  endeavor  to 
imitate  the  movement  of  the  doctor's  lips. 


724  TREATMENT  AND   RESULTS 


Shell-shock:  Impairment  of  vision  (even  com- 
manded men  to  fire  on  kindred  troops!)  Improve- 
ment by  verbal  suggestion,  faradization,  injections. 


Case  517.     (Mills,  October,  1915.) 

A  sergeant-major,  29,  in  private  life  a  bookkeeper,  said 
that  shrapnel  struck  the  ground  in  front  of  him  and  burst  as 
it  struck.  Unconscious  for  a  moment,  the  sergeant-major 
thereafter  saw  everything  imperfectly,  led  his  men  in  the 
wrong  direction,  and  even  commanded  them  to  fire  in  the 
direction  of  his  own  troops. 

Seven  days  afterwards  the  eyes  looked  normal,  fundi  were 
normal,  vision  was  reduced  to  the  perception  of  hand  move- 
ments; with  a  plus  10  sphere  the  right  eye  could  count  fingers 
at 'S  cm.  and  with  a  plus  8  sphere  the  left  eye  could  count 
fingers  at  3  cm.     There  was  a  right  frontal  analgesia. 

Treatment:  Sweating;  rest  in  bed  for  several  weeks;  as- 
surance of  complete  recovery.  There  was  a  slow  but  con- 
stant improvement,  aided  by  faradization  and  injections  of 
strychnine  sulphate  into  the  temporal  region,  but  the  pros- 
pect of  a  return  to  the  front  retarded  the  improvement. 

Re  injections  into  the  temple,  see  also  Case  521  of  Bruce. 
Re  cure  of  blindness,  Grasset  has  a  case  of  a  blind  deafmute 
who  was  cured  by  a  nurse.  She  put  a  pencil  in  his  hand 
and  guided  the  pencil  while  she  wrote  a  question.  The 
patient  replied  in  very  good  MSS.  In  blind  deafmutes  sight 
is  described  as  returning  first,  hearing  next,  and  speech  last. 

For  other  cases  of  blindness,  see  especially  under  Section  C, 
Cases  433  to  438,  with  discussions  thereunder. 

Re  retardation  of  improvement  by  the  prospect  of  further 
military  ser\dce,  Lewandowski  has  insisted  upon  the  strong 
factor  of  the  wish  in  all  such  functional  conditions.  Lew- 
andowski wants  all  functional  cases,  however,  to  be  sent  to 
duty  in  the  rear  or  to  be  discharged  as  unfit. 


TREATMENT  AND  RESULTS  725 


Aphonia :  manipulation  in  larynx. 


Case  518.     (O'Malley,  May,  1916.) 

A  corporal,  28,  had  a  bullet  pass  through  his  neck  from  a 
point  in  the  middle  line  at  the  upper  border  of  the  thyroid 
cartilage  to  a  point  behind  the  right  sternomastoid  muscle, 
two  inches  below  the  point  of  entry.  The  corporal  lost  his 
voice  at  the  time  of  injury,  spat  up  a  teaspoonful  of  blood, 
and  thereafter  was  able  to  whisper  only.  The  laryngoscopic 
examination  betrayed  no  intralaryngeal  lesion.  Treatment 
as  described  below  enabled  the  patient  to  speak.  O'Malley 
describes  his  technique  as  follows: 

The  patient  is  placed  in  the  common  position  for  the 
examination  of  the  larynx,  the  tip  of  the  tongue  being 
seized  in  a  piece  of  linen  by  the  left  hand  fingers  and  the 
laryngeal  mirror  introduced  with  the  right  hand.  The 
patient  is  then  requested  to  say  "e  "  or  cough,  and  if 
the  cords  do  not  approximate,  they  can  be  made  to  do 
so  by  using  moderate  friction  on  the  fauces  and  pharynx 
with  the  mirror  to  excite  secretion.  The  latter  begins 
to  drop  into  the  larynx,  and  acting  as  a  foreign  body,  a 
protective  reflex  is  at  once  excited  which  adducts  the 
cords  to  prevent  the  secretion  from  entering  the  tra- 
chea. At  the  same  time  an  involuntary  cough  is  pro- 
duced to  expel  the  mucus,  and  if  the  friction  and  flow 
of  secretion  are  maintained  and  the  patient  is  urged  to 
cough  vigorously,  voluntary  coughing  and  a  tendency 
to  retching  with  forced  laryngeal  notes  will  rapidly 
follow.  It  is  usually  best  to  persist  until  retching 
occurs,  as  the  cords  are  then  forced  together  to  protect 
the  larynx  and  trachea  from  the  possible  entrance  of 
regurgitated  stomach  contents.  Involuntary  laryn- 
geal sounds  are  thus  produced  and  the  patient  is  con- 
scious of  laryngeal  efTort.  Some  of  these  cases  are  at 
the  moment  very  shallow  breathers,  which  can  be  dem- 
onstrated by  X-ray  screening,  but  the  act  of  retching 
causes  a  wide  excursion  of  the  diaphragm  with  a  more 
pronounced  expiratory  blast,  to  be  rapidly  followed  by 
deeper  inspirations.  This  method  of  treatment  is  best 
carried  out  just  before  a  meal,  as  the  stomach  is  then 
practically  empty  and  the  unpleasant  effects  of  the 
sudden  regurgitation  of  food  are  avoided.     When  the 


726  TREATMENT  AND  RESULTS 

explosive  sounds  accompanying  retching  have  occurred 
two  or  three  times  the  mirror  is  withdrawn,  the  tongue 
released,  and  the  patient  is  requested  to  swallow,  take 
a  deep  breath,  and  cough,  and  then  urged  to  count  up  to 
ten,  directing  his  voice  to  a  certain  point  on  the  ceiling. 
This  method  has  given  me  uniformly  good  results,  and 
was  rapidly  effective  in  all  cases  coming  under  treat- 
ment soon  after  the  onset  of  the  neurosis. 

Re  methods  for  curing  aphonia.  Muck  has  a  method  called 
the  "ball"  method.  A  ball  is  put  into  the  larynx  to  cause  a 
temporary  suffocation,  which  produces  a  reflex  that  starts 
the  adductors.  He  would  apply  the  method  as  soon  as  the 
man  was  well  over  the  shock  that  produced  aphonia.  Muck 
states  that  he  has  applied  the  ball  method,  not  only  to  cases 
of  aphonia,  but  to  cases  of  mutism  and  deafness,  with  success. 

Tilly  mentions  a  case  in  which  the  patient  refused  to  open 
his  mouth,  so  the  device  was  adopted  of  passing  an  electrode 
through  the  left  nostril  so  that  it  finally  reached  the  larynx. 
A  spasm  was  produced,  which  was  carried  to  the  point  of 
considerable  cyanosis,  but  the  aphonia  was  relieved  and  for 
the  first  time  in  three  months  the  man  spoke.  Incidentally 
he  began  to  hear  also. 

Re  treatment  of  aphonia,  Schultz  has  used  the  electric 
current  externally  over  the  larynx,  all  the  while  carrying 
on  a  laryngoscopy.  Schultz  remarks  upon  the  fatigue  that 
may  come  during  the  first  few  sittings.  Roussy  and  Lher- 
mitte  remark  that,  although  aphonia  sometimes  exists  from 
the  outset  of  shock,  it  is  often  a  phase  in  recovery  from 
mutism. 

Liebault  notes  that,  not  only  cases  of  true  nervous  aphonia 
but  cases  of  laryngitis,  apparently  of  infectious  origin,  and 
cases  of  true  voice  strain,  may  also  turn  up  for  treatment. 
Some  men  have  been  improperly  discharged  from  the  army 
for  aphonia  actually  due  to  voice  strain. 


TREATMENT  AND  RESULTS  727 


Hysterical  aphonia  in  a  mechanician  (war  time 
contributory?).  Cure  by  suggestive  manipulation 
of  larynx. 


Case  519.     (Vlasto,  January,  191 7.) 

A  mechanician  was  refitting  an  engine  valve,  when  steam 
was  suddenly  put  on  and  the  drains  were  opened  out.  Some 
of  the  steam  entered  the  throat  of  the  mechanician,  who 
rushed  up,  gasping,  unable  to  speak.  Oedema  of  the  larynx 
was  thought  of;  but  there  was  no  complaint  except  the  in- 
ability to  speak. 

A  month  later  he  was  discharged  to  the  hospital  ship  at 
Plassy,  where  he  got  faradic  treatment,  the  effect  of  which 
was  to  cause  him  pain  without  recovery  of  voice.  The  man 
could  whisper  well  enough  and  cough  fairly  loudly.  The 
vocal  cords  of  the  larynx  appeared  normal  on  laryngoscopic 
examination,  but  adduction  of  the  cords  was  not  be  properly 
effected.  He  was  now  given  rest  and  constant  assurances 
that  he  would  get  well. 

Ten  days  later,  another  laryngoscopic  examination  was 
made,  with  mild  mechanical  stimulation  of  the  air  passage. 
The  patient  remarked  that  he  had  never  been  so  near  being 
able  to  speak  since  his  dumbness  came  on.  The  patient 
was  now  Informed  that  his  muscle  of  talking  was  going  to  be 
replaced  and  that  the  success  of  the  operation  depended  upon 
his  help,  so  that  he  was  to  shout  out  as  soon  as  he  became 
conscious  of  the  physician's  working  Inside  his  throat.  The 
patient  was  given  ether  lightly,  Into  the  second  stage.  When 
consciousness  was  about  to  return,  the  laryngeal  mirror  was 
placed  lightly  on  the  larynx.  The  patient  was  commanded 
and  encouraged  to  count  out  loud  and  shout.  Speech  re- 
turned permanently. 

It  is  to  be  noted  that  there  was  no  specific  war  effect 
underlying  the  phenomena,  unless  we  regard  the  fact  of  its 
being  war  time  as  contributory  to  the  shock  produced  by  an 
incident  in  every  day  engine  room  duties. 


728  TREATMENT  AND   RESULTS 


Gradual   onset   of   mutism   and    amnesia  without 
special  occasion.     Faradism.     Dream. 


Case  520.     (Smyly,  April,  191 7.) 

A  soldier  was  slightly  wounded  in  the  arm  and  returned 
to  the  trenches.  Later  he  found  himself  in  hospital  at 
Boulogne,  unable  to  speak  and  unable  to  remember  what 
had  happened  to  him  from  the  time  he  was  in  the  trenches. 
It  appears  that  his  voice  and  memory  had  gradually  disap- 
peared, according  to  what  was  told  him  by  his  comrades. 

A  month  afterward,  in  a  London  hospital,  the  patient  was 
roused  suddenly  from  sleep,  and  then  proved  able  to  speak, 
although  there  was  great  difficulty  in  getting  each  word  out. 
Two  months  later,  he  went  to  bed,  feeling  indisposed,  in  the 
night  had  a  kind  of  fit,  and  remained  unconscious  until  the 
following  night;  the  next  morning,  his  voice  was  again  lost. 
The  aphonia  persisted  for  a  fortnight,  and  the  patient  could 
hear  only  loud  shouting  when  close  to  his  ear.  He  was 
anxious  to  get  well  and  requested  electricity  from  the  physi- 
cian. Dr.  Smyly,  having  heard  probably  of  another  case 
cured  thereby.  Dr.  Smyly  applied  faradic  current  to  the 
larynx  externally,  instructing  the  patient  to  blow  at  the 
same  time.  At  first  the  patient  spoke  so  low  that  he  could 
not  hear  himself  speak,  but  on  suggestion  succeeded  in 
speaking  up  loudly  enough.  He  was  shortly  able  to  speak 
and  hearing  improved.  The  climax  arrived  with  a  bad 
dream  one  night,  from  which  the  patient  awoke  in  a  fright 
and  found  himself  able  to  hear  and  speak  perfectly. 

Re  nocturnal  spontaneous  cures,  see  observations  by  Mott 
under  Case  473.  Note  also  in  this  case  the  presence  of 
what  Mott  has  termed  "  the  atmosphere  of  cure." 

Re  relapses,  see  Case  476  as  well  as  remarks  under  Case 
474.  Re  special  cases  of  mutism,  Goldstein  has  insisted 
upon  a  greater  individualization  of  treatment  for  func- 
tional mutes  than  even  for  other  neurotics,  and  advocates 
the  establishment  of  schools  within  the  hospitals  and  after- 
care institutions.     He  thinks  the  problem  very  serious. 


TREATMENT  AND  RESULTS  729 


Shell-shock  blindness:  Cure  by  a  course  of  injec- 
tions in  the  temple. 


Case  521.     (Bruce,  May,  1916.) 

A  soldier  from  Gallipoli  was  admitted  to  the  Royal  Vic- 
toria Hospital  at  Edinburgh,  blind.  He  had  been  at  Gal- 
lipoli from  May  i,  1915,  until  August  12,  when  a  shell  explo- 
sion blew  in  his  trench  and  buried  him.  He  was  dug  out 
nervous  and  tremulous.  Shortly  afterwards  there  was  the 
bright  flash  of  a  second  shell,  and  amnesia  set  in  until  he 
found  himself  in  hospital.  He  could  not  see  at  all  with  the 
left  eye  and  the  sight  of  the  other  was  poor.  He  arrived  in 
Scotland,  October  9.  He  was  nervous,  excitable  and  now 
somewhat  depressed,  complaining  of  blindness  and  pain  in 
the  left  eye,  and  headache.  The  left  eyelid  drooped.  The 
fundus  was  normal.     He  had  not  been  given  an  anesthetic. 

It  was  explained  to  him  that  the  eye  had  not  been  injured; 
that  it  had  become  weak  from  the  explosion;  that  he  would 
be  given  a  series  of  injections  into  the  left  temple  of  a  strong 
drug  which  would  restore  the  sight  of  the  eye. 

Gradually  increasing  quantities  of  normal  saline  solution 
were  given  every  morning.  After  four  days  he  said  that  the 
treatment  was  doing  him  good.  A  week  later  he  said  that  the 
eye  was  much  stronger.  After  the  fifteenth  injection  he  could 
not  sleep.  The  headache  was  worse,  and  there  was  ''moving 
about  inside  his  head."  Early  in  the  morning  he  went 
to  sleep  after  a  period  of  restlessness.  He  awoke  at  eight 
o'clock  able  to  see  perfectly,  and  was  overjoyed  at  the  result. 
There  was  some  blurring  and  four  days  later  he  said  he  was 
becoming  blind  again.  More  normal  saline  was  injected, 
causing  pain.  After  that  there  was  no  relapse,  and  the  man 
was  sent  back  to  his  unit. 

Re  Shell-shock  blindness,  Ormond  and  Hurst  recom- 
mend a  light  hypnosis;  taking  the  functionally  blind  man 
into  a  dark  room  and  requesting  him  to  make  his  mind  a 
blank.  Some  cases  are  refractory.  An  anesthetic  may  be 
used  with  suggestion  in  the  semi-conscious  stage. 


730  TREATMENT  AND   RESULTS 


Deafness,  cured  by  suggestion  in  writing. 


Case  522.     (BuscAiNO  and  Coppola,  1916.) 

L.  G.,  20  years  old;  fusileer.  (Mother  of  neuropathic  con- 
stitution. Father  died  in  50th  year  of  heart  disease.  One 
brother  had  hemiparesis  from  infantile  cerebropathia.)  The 
patient  suffered  from  infantile  otitis  media  bilateralis,  which 
was  followed  by  abundant  chronic  otorrhea  from  his  fif- 
teenth year.  He  relates  that  for  a  long  time  he  was  obliged 
to  wear  a  very  large  handkerchief  on  his  shoulders  to  receive 
the  pus,  which  came  from  an  ear.  No  sex  disease.  Noth- 
ing of  importance  in  the  physical  anamnesis. 

Patient  entered  the  army,  Jan.  15,  1915.  In  May,  he  was 
sent  to  the  front  (Basso  Isonzo).  Towards  the  end  of  July, 
while  he  was  in  the  trench,  a  grenade  exploded  a  short  dis- 
tance from  him,  causing  slight  abrasions  at  the  nape  of  the 
neck  and  in  the  fleshy  part  of  the  left  calf.  He  was  picked 
up  in  an  unconscious  state,  and  taken  to  the  hospital  at 
Cervignano,  where  he  was  admitted  as  a  deafmute  and  was 
given  electric  treatments.  After  18  days  or  so,  first  stam- 
mering and  then  pronouncing  with  difficulty  a  few  words, 
he  finally  regained  his  speech  entirely.  Deafness  continued, 
however. 

Being  transported  to  a  special  hospital  in  Florence,  he 
was  in  a  state  of  psychic  excitement  for  several  days,  showing 
also  visual  hallucinations  —  saw  "many  soldiers,"  saw  "many 
soldiers  all  about  him."  He  was  treated  with  chloral  and 
bromide.  The  suspicions  of  several  physicians  were  aroused 
by  the  obstinate  declaration  by  the  patient  that  he  was  in- 
curably deaf. 

On  being  admitted  to  the  clinic  on  August  22,  he  showed 
complete  deafness  in  addition  to  a  slight  degree  of  stupor; 
he  remained  impassive  to  the  glance  of  his  questioner  without 
showing  signs  of  worry  about  his  condition,  nor  did  he  make 
any  effort  to  make  himself  understood  by  making  lip-move- 
ments (which  is  in  contrast  to  another  patient  affected  by 
organic  deafness,  who  on  the  contrary  made  great  efforts  to 


TREATMENT  AND   RESULTS  731 

understand  anything  said  to  him,  clearly  showing  his  great 
grief  over  his  incapacity). 

He  failed  to  respond  to  auditory  stimuli  either  by  air 
or  by  bone  conduction.  It  was  possible  from  the  begin- 
ning to  exclude  suspicion  of  simulation;  during  the  day, 
indeed,  it  was  not  possible  by  any  of  the  repeated  attempts 
to  awaken  surprise  in  the  patient  by  means  of  an  acoustic 
stimulus.  At  night,  while  the  patient  slept,  it  was  possible, 
however,  to  awaken  him  by  calling  his  name,  or  by  making 
a  fairly  loud  sound;  the  patient  would  then  open  his  eyes 
but  was  quite  unable  to  hear.  Neither  confusion  nor  hallu- 
cinations were  in  evidence. 

He  was  able  to  converse  very  well  and  spontaneously  (he 
remembers  having  lost  consciousness  at  the  explosion  of  the 
grenade  and  not  coming  to  until  after  his  arrival  at  the  hos- 
pital at  Cervignano) ;  he  read  correctly  both  mentally  and 
aloud,  and  answered  by  signs  the  questions  put  to  him  in 
writing.  Being  face  to  face  with  hysterical  traumatic  deaf- 
ness, notwithstanding  no  other  hysterical  phenomena  were 
noticed,  a  successful  attempt  was  made  with  suggestive 
therapy,  the  patient  being  emphatically  assured  (always  in 
writing)  that  the  following  Sunday  his  hearing  would  be  re- 
stored without  doubt.  The  following  Sunday,  in  fact,  dur- 
ing the  visit  of  a  lady  (one  of  his  friends) ,  hearing  in  his  left 
ear  was  suddenly  and  almost  completely  restored  to  the 
patient.  He  was  in  profound  emotion  on  account  of  this, 
and  upon  the  appearance  of  the  physician  he  had  a  hard 
weeping  spell.  During  the  following  day,  he  began  slowly 
to  hear  with  the  right  ear. 

During  the  latter  part  of  his  stay  at  the  clinic,  however 
(until  September  24,  19 15),  a  slight  hypo-acusia  in  the  right 
ear  persisted,  along  with  severe  headaches  and  pains  in  the 
left  ear  (which  the  patient  compared  to  the  suffering  as  a 
child  with  otitis). 

At  the  otoscopic  examination  by  a  specialist,  only  residuals 
of  the  old  catarrhal  otitis  with  retraction  of  the  tympanic 
membrane  were  found. 


732  TREATMENT  AND  RESULTS 


Shell-shock    story   reproduced    in    hypnosis.     Re- 
covery. 


Case  523.     (Myers,  January,  1916.) 

A  private  had  been  found  wandering  in  a  village,  in  shirt 
and  socks,  unable  to  give  name,  regiment,  or  number.  He 
was  admitted  at  a  field  ambulance,  and  seen  by  Major  Myers 
three  days  later.  No  Christian  name  seemed  familiar  to 
him.  The  past  w^as  a  blank.  He  was  depressed.  There  was 
numbness  over  the  occiput.  The  legs,  hands  and  tongue 
were  tremulous.  The  left  arm  and  leg  and  the  left  side  of  the 
face,  chest  and  abdomen  were  hypalgesic.  The  knee-jerks 
were  exaggerated ;  pseudo-clonus  of  left  knee  and  right  ankle. 
There  had  been  a  nightmare  of  bombs  thrown  into  trenches  — 
one  thrown  by  a  German  hit  him  in  the  neck  and  woke  him 
up  in  a  cold  sweat. 

In  hypnosis  the  dream  was  repeated,  and  points  about  his 
previous  life  were  dragged  out  piecemeal.  Next,  the  names 
of  village  and  near-by  town,  and  finally  his  own  name,  regi- 
ment and  number  were  elicited.  After  the  bomb-throwing, 
he  said,  "  I  must  have  gone  off  my  head  and  run  aw^ay.  I 
must  have  taken  off  my  clothes  in  a  field.  I  spent  the  first 
night  under  a  hedge.  I  spent  the  next  two  nights  in  a  wood. 
I  ate  nothing.  The  next  night  I  was  walking  along  a  road 
on  the  outskirts  of  a  village  and  I  was  taken  to  a  house  by 
two  men."  On  waking,  he  proved  unable  to  remember  these 
things  and  was  promptly  rehypnotized,  whereupon  the 
memories  became  clearer  and  more  ample.  More  powerful 
suggestion  was  given,  and  complete  recovery  of  memory 
followed  the  second  period  of  hypnotism.  The  pupils  be- 
came larger.  The  despondency  disappeared,  together  with 
the  occipital  numbness  and  the  left-sided  hypalgesia.  He  was 
transferred  to  a  base  hospital,  and  thence  after  three  weeks 
to  a  hospital  in  England,  made  an  uninterrupted  recovery, 
and  rejoined  his  regiment. 


TREATMENT   AND   RESULTS  733 


Shell-shock    story    reproduced   in   hypnosis.     Re- 
covery. 


Case  524.     (Myers,  January,  191 6.) 

Private,  29,  seen  by  Major  Myers  in  a  base  hospital  the 
day  after  entrance,  was  in  a  stupor  from  which  he  had  to  be 
repeatedly  roused  to  answer  questions.  He  could  recall 
neither  name,  regiment  nor  age,  and  was  unable  to  write  or 
read  except  a  few  letters  in  very  large  type.  Twice  he  said 
the  words  war  and  comrade,  and  made  a  gesture  as  if  follow- 
ing. He  agreed  that  a  shell  came  and  intimated  that  he  had 
pains  in  the  forehead.  He  could  not  hold  his  hands  out  for 
many  seconds  without  dropping  them.     Knee-jerks  brisk. 

Four  days  later  he  was  very  little  better,  never  having 
spoken  voluntarily,  but  replying  yes  to  the  utterance  of  his 
name,  and  was  able  w^ith  great  effort  to  write  his  name.  He 
still  intimated  his  severe  headache.  The  next  day  the  names 
of  his  two  children  were  given.  He  could  not  read  aloud  the 
figure  2  but  held  up  two  fingers.  Next  day,  he  gave  syllable 
by  syllable  his  wife's  name  from  her  photograph. 

A  week  from  admission  he  was  hypnotized  and  persuaded 
to  talk  about  the  events  that  preceded  his  disorder,  breathing 
excitedly,  gesturing,  and  evidently  visualizing  the  scenes.  He 
had  been  in  the  trenches,  had  been  sent  to  draw  water  at  a 
camp,  and  had  been  knocked  down  when  two  or  three  shells 
burst  over  him.     He  carried  out  post-hypnotic  suggestions. 

He  was  hypnotized  again,  two  days  later,  and  now  de- 
scribed how,  after  shelling,  he  had  lain  on  the  ground,  dazed ; 
had  risen,  picked  up  the  water  bottle,  returned  to  the  trenches, 
and  then  lost  all  sense  and  reason.  He  recalled  how  his  mates 
had  told  him  he  was  silly,  but  had  lost  all  interv'ening  mem- 
ories. But  the  full  details  were  elicited  by  persuasion.  Next 
day  he  complained  that  he  still  wrote  vAth.  difficulty.  Under 
hypnosis,  his  speech  and  writing  were  restored  to  normal. 
He  was  discharged  two  days  later  to  an  English  hospital. 

He  was  then  passed  for  foreign  service,  being  prevented 
from  active  service  in  the  field  by  occasional  severe  headaches. 


734  TREATMENT   AND   RESULTS 


Burial  after  explosion  of  a  "  coal  box  "  :  Automatism, 
amnesia,  deafmutism:   Recovery  by  hypnosis. 


Case  525.     (Myers,  September,  191 6.) 

A  sergeant,  18,  with  nineteen  months  service  in  the  army, 
1 1  months  in  France,  was  seen  by  Lt.  Col.  Myers  at  a  clear- 
ing station  to  which  he  had  been  transferred  after  three  days 
in  another  clearing  station,  with  a  note  "  Found  in  the  streets 

of  B ,  asking  his  way  to  the  fire  trench ;   could  not  be 

got  to  speak  on  admission  nor  since;  seems  deaf,  but  now 
writes  rationally." 

Mute  and  very  deaf  at  the  second  C.  C.  S.,  he  regained  a 
good  deal  of  his  hearing  with  encouraging  talk  and  also  be- 
came able  to  cough  and  utter  P,  B,  F  and  S,  finally  whispering 
name,  regimental  number,  and  the  like.  At  the  same  time 
he  could  write  fluently.  After  being  buried  he  had  lost 
himself  until  he  had  asked  his  way  of  a  military  policeman 

at  the  crossroads  in  B .     There  was  amnesia  again  until 

he  had  been  48  hours  in  the  clearing  station  at  B .     The 

throat  hurt  as  if  it  were  pulled  down  when  he  tried  to  speak, 
and  his  head  ached  when  he  tried  to  remember.  There  was 
much  tremor,  especially  of  right  arm.  In  a  quiet  room  ad- 
joining, the  tremors  increased  and  there  was  much  agitation. 
Lt.  Col.  Myers  suggested  cure  and  encouraged  the  man, 
finally  inducing  a  mild  hypnotic  state  in  which  he  spoke  aloud, 
at  first  hesitatingly,  later  fluently. 

The  man  eventually  remembered  what  had  happened  after 
he  had  extricated  himself.  He  had  run,  as  he  thought, 
towards  the  fire  trench,  taken  a  wrong  direction,  and  met  a 
Frenchman  who  gave  him  eggs  and  bread,  allowed  him  to 

sleep  on  a  couch,  put  him  on  a  cart  and  drove  him  to  B . 

He  was  then  very  giddy  and  asked  his  way  of  the  policeman. 
The  shell  by  which  he  was  "terribly  shaken"  was  a  "coal  box." 
Posthypnotic  suggestion  that  the  headache  would  not  recur 
and  that  he  would  shake  hands  with  the  orderly  was  success- 
ful. He  now  talked  in  a  proper  voice,  at  first  hesitatingly. 
He  looked  another  man  as  his  clav-colored  face  resumed  a 


TREATMENT   AND   RESULTS  735 

normal  aspect.  After  a  good  night's  sleep  he  was  evacuated 
to  a  base  hospital,  thence  to  an  English  hospital,  whence  he 
wrote  six  days  later  in  gratitude  for  the  successful  treatment, 
stating  that  he  was  now  nearly  well  and  hoped  to  be  fit  for 
light  duty. 

Six  weeks  later  he  wrote  that  he  was  still  dizzy.  He  also 
remembered  certain  further  details  of  his  experience;  how  he 
had  wandered  into  a  listening  sap  in  front  of  the  Huns' 
barbed  wire  and  had  had  a  tussle  with  three  Huns,  after  which 
he  was  buried  during  the  heavy  shelling. 

This  case  belongs  in  the  group  termed  by  Myers 
"A  Group,"  namely,  the  physical  group,  in  which  the 
patient  has  been  lifted,  buried  or  knocked  over  by  a 
shell  or  otherwise  felt  physical  or  chemical  effects  of  an 
explosion  (in  contrast  with  the  B  Group,  or  psychical 
group,  in  which  fear  of  the  noise  or  emotional  response 
to  the  mutilation  of  companions  is  the  exciting  cause). 
Predisposing  affections  occur  as  often  in  the  physical 
group  as  in  the  psychical  group.  The  average  age  of 
mutism  cases  seen  by  Lt.  Col.  Myers  is  twenty-five. 
Mutism  is  rare  among  commissioned  officers.  Lt.  Col. 
Myers  has  heard  of  but  one  or  two  cases. 

With  respect  to  the  technique  of  getting  these  men  to 
utter  sounds,  Lt.  Col.  Myers  states  that  he  first  assures 
the  patient  that  he  has  already  cured  many  cases  of 
loss  of  speech  by  the  method  about  to  be  employed. 
The  patient  is  next  asked  to  copy  his  teacher  as  the 
sounds  (not  the  vowels)  B,  D,  finally  V,  S  and  K  are 
made.  The  patient  is,  as  a  rule,  shortly  induced  to 
make  the  necessary  movements  of  lips,  tongue  or  throat. 
"  You  see  you  are  beginning  to  talk.  Now  let  me  hear 
you  cough."  The  patient  coughs.  "  You  see  you  are 
able  to  make  a  noise.  I  want  you  next  to  cough  out 
an  A  (Continental  pronunciation)."  After  a  time  the 
patient  adds  this  vowel  to  the  cough.  Other  vowels 
are  now  taught  him.  Eventually  a  consonant  is  pre- 
fixed to  the  vowel  instead  of  the  cough.  The  patient  is 
now  delighted  with  his  progress  and  can  shortly  repeat 
surname  and  regimental  number. 


736  TREATMENT   AND    RESULTS 


Mutism:   Recovery  by  hypnosis. 


Case  526.     (Hurst,  191 7.) 

A  transport  driver,  31,  was  run  over  by  a  loaded  wagon  at 
Gallipoli  in  May,  191 5,  and  fractured  his  pelvis.  He  re- 
mained perfectly  conscious  but  unable  to  speak  for  three  days. 
At  the  beginning  of  August,  when  he  was  admitted  to  the 
war  hospital,  he  still  spoke  with  great  difficulty  and  with 
contortions  of  his  face.  Even  when  he  did  not  speak,  he  had 
facial  contortions  and  that  mental  condition  characteristic  of 
tic,  namely:  although  he  was  able  to  control  the  contortions 
by  will,  he  felt  uncomfortable  during  the  control  and  finally 
gave  way  to  the  irresistible  impulse. 

Under  hypnotism,  it  was  suggested  to  him  that  he  would 
be  able  to  speak  without  difficulty  and  would  no  longer  have 
the  contractions  of  the  face.  When  he  came  out  of  hypnosis 
he  was  able  to  talk  quite  normally,  sang  next  evening  at  a 
concert,  and  a  few  days  later  he  took  part  in  a  play.  The 
facial  contortions  persisted  in  hypnosis  and  even  afterwards, 
but  vanished  after  a  second  hypnosis. 

Re  hypnosis  as  treatment  of  mutism,  Ballard  remarks 
that  a  genuine  return  of  speech  and  a  merely  hypnotic 
speech  must  be  distinguished. 

Nonne  is  the  great  exponent  of  the  use  of  hypnotism  in 
treatment  of  the  war  hysterias.  He  got  as  good  results 
from  high  as  from  lower  classes  of  men.  He  remarks  that 
the  hypnosis  does  not  protect  against  recurrence  if  the  patient 
again  falls  under  the  original  conditions  that  brought  about 
the  first  attack.  Hypnosis  may  be  used  also  as  a  diagnostic 
measure  between  functional  and  organic  cases.  Even  tics 
and  tremors  have  been  at  times  cured. 

Re  employment  of  hypnotism,  Hurst  suggests  that  It  may 
well  be  used,  not  only  In  mutism,  but  In  hysterical  deafness, 
blindness,  and  occasionally  In  psychasthenla.  It  Is  not  a 
cure-all  for  the  war  hysterias,  but  is  to  be  used  as  a  not  In- 
frequent form  of  treatment.  Nonne  claims  cures  of  51  out 
of  63  cases  of  hysteria  major  (28  rapidly,  23  more  gradually). 
Ten  of  his  63  proved  refractory  to  hypnosis  altogether. 


TREATMENT  AND  RESULTS  737 


Stammering:   Cured  by  hypnosis. 


Case  527.     (Hurst,  191 7.) 

An  Australian,  22,  wrote  the  following,  August  21,  1916: 
"  You  may  be  a  little  surprised  to  hear  that  I  am  in 
the  Hos.  suffering  from  shell-shock,  which  has  taken 
away  my  speech  and  hearing.  It  is  some  sixteen  days 
now  since  it  happened.  .  .  .  We  were  in  the  trenches 
and  going  for  dear  life,  when  two  of  us  spotted  a  Ger- 
man machine  gunner  in  a  hole,  so  we  made  up  our 
minds  to  have  him.  We  made  a  charge  at  him,  and  I 
just  remember  getting  to  him  when  a  high-explosive 
shell  burst  at  my  head;  it  seemed  as  if  it  burst  inside 
my  head;  everything  went  black.  I  tried  to  call  out 
and  couldn't,  and  I  could  not  hear  my  mates  —  only 
just  a  terrible  bursting  in  my  head  all  the  time.  I 
never  remembered  anything  more  until  I  came  to  on  the 
boat.  The  Drs.  have  told  me  that  I  will  get  alright  in 
time.  I  saw  a  good  deal  of  France.  .  .  .  There  is  not 
a  young  man  there  who  is  not  in  the  Army.     The  girls 

and  women  work  in  the  fie " 

The  abrupt  ending  of  the  letter  was  due  to  the  entrance  of 
Major  Hurst.  The  patient  had  been  hypnotized  but  his 
deafness  had  persisted  during  the  hypnotic  sleep,  so  that  sug- 
gestions could  not  be  effectively  taken.  He  heard  nothing 
whatever  during  a  very  heavy  thunderstorm,  was  unable  to 
make  any  sign  whatever,  and  could  not  even  cough. 

He  was  now  told  in  writing  that  his  speech  and  hearing 
would  be  restored  when  ether  was  given.  After  a  few  whiffs, 
he  struggled  and  before  he  was  under  began  to  repeat  the 
word  "  Mother."  Etherization  was  discontinued  before  his 
limbs  had  even  become  relaxed.  As  he  was  coming  to,  he 
was  requested  to  repeat  various  words,  and  when  the  anes- 
thetic had  passed,  he  was  talking  normally  and  had  completely 
recovered  hearing. 

Now,  however,  his  memory  had  become  a  complete  blank. 
From  a  short  time  before  his  shell-shock  up  to  the  moment  of 
his  regaining  consciousness  after  etherization,  he  remembered 
nothing  of  his  loss  of  speech  or  hearing,  nothing  about  the 
events  in  his  letter,  and  nothing  about  Major  Hurst,  whom  he 


738  TREATMENT  AND   RESULTS 

felt  he  had  not  previously  seen.  According  to  Hurst,  this 
patient  had  become  (a)  speechless  from  fright  at  the  time  of 
the  shell  explosion,  (b)  deaf  from  the  noise  of  the  explosion, 
and  (c)  unconscious  from  the  windage.  After  he  came  to  at 
the  time  of  the  explosion,  an  autosuggestion  to  the  effect 
that  he  had  lost  his  power  of  speech  and  hearing  occurred. 
Ether  broke  down  this  inhibition  of  speech  and  hearing  by 
interfering  with  the  control  of  the  high  over  lower  cerebral 
centers. 

Re  emotional  stammering,  Chavigny  treats  by  voice  gym- 
nastics, rhythmical  breathing  movements,  sounds  spoken  by 
metronome  with  simultaneous  movements  of  arms  or  trunk, 
and  by  singing.  Re  hysterical  stuttering,  Roussy  and  Lher- 
mitte  remark  that  the  symptoms  are  always  very  pro- 
nounced, come  on  suddenly,  and  cease  just  as  suddenly  under 
the  influence  of  electrical  treatment.  The  history  will  dif- 
ferentiate hysterical  stuttering.  The  effects  of  treatment 
will  also  help.  Genuine  non-hysterical  stammering  may,  of 
course,  be  increased  through  emotion  or  shock.  Dundas 
Grant  aids  the  stutterer  by  having  him  twist  a  button  or 
carry  out  some  other  muscular  movement  simultaneously 
with  the  attempt  to  speak.  He  also  has  the  patient  endeavor 
to  expand  the  lower  part  of  his  chest  during  the  effort. 

MacMahon  notes  that  Shell-shock  stammering  is  chiefly 
a  difficulty  with  vowel  sounds  and  voiced  consonants,  and 
amounts  to  a  speech  inhibition,  accompanied  sometimes  by 
amnesia  for  words  and  suggesting  a  form  of  aphasia.  Mild 
cases  of  such  stammering  are  cured  simultaneously.  Mac- 
Mahon relies  in  part  upon  especially  regulated  breathing 
movements  and  the  attendant  sense  of  repose.  The  cases  of 
old  cured  stammering  that  have  come  back  under  Shell- 
shock  are  harder  to  treat. 


TREATMENT  AND   RESULTS  739 


Two  burials;   shell-shock:  Mutism  and  amnesia. 
Recovery  aided  by  hypnosis. 

Case  528.     (Myers,  January,  1916.) 

Major  C.  S.  Myers  recites  hypnotic  cure  in  a  case  of  mutism. 
He  remarks  that  malingering  is  sometimes  suspected  in  these 
cases.  There  was,  however,  in  this  case  a  severe  constipation 
which  lasted  five  days  from  the  shock,  and  a  retention  of 
urine  with  catheterization  during  the  same  period.  This 
private,  32  years,  came  to  a  base  hospital,  mute  but  able  to 
read  and  write  as  follows : 

"  I  was  buried  alive  on and  again  on [5 

months  and  4^  months  respectively  before  admission], 
and  then  I  had  the  misfortune  to  have  two  shells  burst 

over  me  on [four  days  before  admission].     There 

was  shelling  for  about  20  minutes  and  then  two  bursted 
over  my  head.     I  did  not  remember  any  more  until 
you  came  to  see  me,  but  I  am  still  living  in  hopes  to 
regain  my  speech  back." 
It  seems  that  he  had  wandered  off  with  a  lance-corporal  for 
three  days  after  the  first  burial,  and  neither  he  nor  his  com- 
rade were  able  to  find  their  regiment. 

Understanding  was  slow  and  look  vacant.  There  were 
jerky  movements  of  the  arms  and  a  snoring  sound  from  the 
nasopharynx.  Voluntary  movements  were  restricted,  weak, 
slowly  executed,  jerky,  and  incoordinated,  but  not  tremulous. 
Station  was  unsteady;  failure  in  finger-to-nose  test.  He 
could  imitate  the  sound  ah,  and  the  consonants  5  and  p. 

Knee-jerks  exaggerated;  plantars  flexor;  abdominal  re- 
flexes absent;  pupils  reacted;  eye  movements  normal; 
moderate  restriction  of  visual  fields  on  temporal  side;  watch 
not  heard  even  in  contact  with  ear;  heard  better  by  air  than 
by  bone  conduction. 

In  the  next  two  days,  the  patient  became  brighter  and 
movements  became  better.  On  the  seventh  day  stupor  and 
ataxia  had  disappeared.  Familiar  names  could  be  repeated 
and  the  next  day  could  be  given  on  request.  The  patient 
would  sweat  profusely  in  giving  replies.  There  was  no  spon- 
taneous speech.     A  week  later  speech  had  improved. 


740  TREATMENT  AND   RESULTS 

Under  hypnosis  he  spoke  more  fluently  though  feebly,  and 
became  emotional  upon  being  questioned  as  to  trench  life, 
waking  up  suddenly  from  hypnosis  and  wiping  the  sweat 
from  his  chest. 

The  next  day,  forgotten  events  of  the  second  burial  were 
recalled  together  with  what  followed.  Post-hypnotic  sugges- 
tion of  the  performance  of  eccentric  actions  was  successful. 

Next  day  his  memory  had  returned  save  in  reference  to  the 
two  days'  wandering  after  the  first  burial;  and  under  hyp- 
nosis the  events  of  those  two  days  were  recalled.  He  was 
then  transferred  to  an  English  hospital. 

Re  hypnosis  for  "war  shock,"  Eder  remarks  that  the  usual 
objections  to  hypnosis  cannot  apply  because  the  majority  of 
cases  have  no  neuropathic  antecedents.  Eder,  as  psycho- 
analyst, endeavors  to  level  hypnotic  suggestion  against  the 
so-called  "complexes."  Elliot  Smith  and  Pear  commend 
Lt.-Col.  Myers'  results,  but  regard  the  results  of  hypnotic 
treatment  as  brilliant  but  erratic.  Colin  Russel,  regarding 
hypnotism  as  an  induced  hysteria,  remarks  that  a  true 
hysteria  can  hardly  be  cured  by  adding  more,  although  he 
has  sometimes  used  the  treatment  with  apparent  success. 
Podiapolsky  notes  that  some  17  per  cent  of  his  functional 
cases  will,  at  a  word,  drop  off  into  an  artificial  deep  slumber. 
He  thinks  chloroform  should  not  be  given  to  these  subjects 
without  an  attempt  to  secure  this  artificial  deep  slumber 
first.  Chavigny,  highly  commending  suggestion,  notes  that 
the  use  of  hypnotism  is  prohibited  in  military  hospitals  in 
France.  A  remark  of  Smirnow  indicates  that  the  Russian 
authorities  also  look  with  disfavor  upon  hypnosis,  but  he 
notes  certain  patients  whom  he  cured  by  hypnosis,  so  that 
apparently  Russia  did  not  absolutely  forbid  the  use  of  hyp- 
nosis in  war  cases.  Another  Russian,  Arinstein,  prefers  the 
Dubois  method  to  hypnosis. 

Roussy  and  Lhermitte  definitely  state  that  the  psycho- 
therapy of  Dejerine,  Dubois,  and  Babinski  beneficially  re- 
places hypnotic  suggestion,  "which  ought  definitely  to  be 
rejected."  However,  if  the  conclusions  of  Bernheim  are 
sound,  there  can  be  no  theoretical  claim  of  distinction  be- 
tween hypnosis  and  other  forms  of  suggestion. 


TREATMENT  AND  RESULTS  74I 


Fifteen  bayonet  wounds ;  recommendation  for  Vic- 
toria Cross:  Hysterical  contracture  of  hand,  re- 
vealed by  hypnosis  as  the  bayonet  clutch. 


Case  529.     (Eder,  August,  1916.) 

A  left-handed  Irishman,  23,  on  December  22,  1915,  got 
15  bayonet  wounds,  14  of  which  were  on  the  right  side  of  the 
body.  He  was  in  the  trenches  with  23  men,  when  they  were 
attacked  by  about  200  Turks.  He  and  a  sergeant  leaped  out 
of  the  trench  into  a  bayonet  attack  with  Turks. 

He  was  admitted  to  the  hospital  January  26,  1916,  for  a 
hysterical  contracture  of  the  right  hand.  The  fingers  were 
semi-flexed  and  could  not  be  passively  extended.  Col.  Purves 
Stewart  noted  that  there  was  an  anesthesia  and  analgesia  to 
pin-pricks  and  cotton  wool  on  the  whole  of  the  right  arm. 
"  At  the  beginning  of  the  examination,  the  patient  felt  pin- 
pricks at  the  wrist;  as  examination  continued,  the  boundary 
of  anesthesia  steadily  increased  until  it  reached  the  shoulder, 
by  which  time  the  previously  sensitive  spots  were  now  anes- 
thetic."    Later  there  was  a  complete  right  hemianesthesia. 

In  telling  his  story,  this  soldier  repeatedly  emphasized  that 
"  You  must  clutch  your  rifle  very  firmly  and  never  let  it  up, 
guarding  yourself  all  the  time."  This  was  the  explanation 
of  the  contracture.  According  to  Eder,  in  the  unconscious, 
he  was  still  clutching  the  rifle,  fighting  the  good  fight,  and 
symbolizing  the  desire  by  the  grasping  hand.  In  hypnosis, 
suggestion  was  made  that  the  fight  was  over  and  the  rifle 
could  be  let  go,  whereupon  the  hand  was  immediately  relaxed. 

The  analgesia,  thinks  Eder,  was  present  during  the  fight 
and  passed  away  subsequently.  In  fact,  the  soldier  said  that 
he  felt  no  pain  during  the  fight  and  did  not  know  that  he  was 
wounded  until  his  attention  was  called  to  the  fact  that  blood 
was  flowing  from  him.  According  to  Eder,  the  unconscious 
mind  refused  to  feel  pain.  At  Col.  Stewart's  first  prick  or 
two  "  the  unconscious  took  no  notice,  but  as  the  pricks  con- 
tinued, the  former  memory  was  revived  and  the  unconscious 
became  on  guard."     He  had  been  recommended  for  the  V.  C. 


742  TREATMENT  AND   RESULTS 


Gunshot  of  forearm:  Hysterical  contracture,  wrist 
and  fingers :  Cure  by  hypnosis,  "indecently  quick." 


Case  530.     (NoNNE,  December,  1915.) 

An  infantryman,  without  special  hereditary  taint  and  pre- 
viously well,  was  shot  September,  1914,  in  the  right  forearm. 
A  paralysis  of  the  hand  and  fingers  persisted  after  the  wound 
had  healed.  Several  reserve  hospitals  failed  to  cure  the 
paralysis. 

Eight  months  after  the  injury  he  arrived  at  Nonne's  clinic 
at  Eppendorf,  with  a  flexor  contracture  of  the  right  wrist 
joint  as  well  as  of  the  fingers  (exclusive  of  thumb).  The 
finger  tips  were  deeply  sunk  in  the  flesh  of  the  palm.  Ex- 
tension could  only  be  brought  about  against  strong  resistance. 
There  was  a  total  anesthesia  for  all  sensations  in  the  hand  and 
fingers.     No  contraction  of  visual  fields. 

The  patient,  upon  suggestion,  fell  immediately  into  hyp- 
nosis. At  first  the  contracture  was  released  with  some  diffi- 
culty; then,  with  greater  ease,  and  then  without  any 
resistance  whatever.  During  the  same  hypnotic  seance  the 
patient  finally  became  able  to  extend  actively  both  fingers 
and  wrist;  and  next  day,  after  the  patient  had  convinced 
himself  of  his  cure,  he  was  abl  e  voluntarily  to  stretch  the  hand 
and  fingers  with  normal  amplitude  and  power.  The  disturb- 
ance of  sensibility  had  spontaneously  disappeared. 

This  cure  was,  from  the  patient's  point  of  view,  Indecently 
quick.  He  said  everybody  must  feel  he  was  a  malingerer,  and 
in  fact  he  felt  so  himself.  He  went  back  into  service,  where 
he  had  been  for  several  months  at  the  date  of  Nonne's  report. 

Re  Nonne's  enthusiasm  for  hypnosis,  see  under  Case  526. 
Nonne,  contrary  to  Babinski  and  Froment,  would  regard 
even  the  severe  and  obstinate  vasomotor  disturbances  as 
purely  functional  and  as  not  even  **  sub-organic."  The  basis 
of  this  belief  is  that  hypnosis  cures  these  phenomena  as  well 
as  various  tics  and  pertinacious  tremors.  French  observers 
consider  that  these  tics  and  tremors  may  even  be  organic 
in  their  nature,  basing  their  ideas  upon  the  non-success  of 


TREATMENT   AND   RESULTS  743 

suggestion.  (It  may  be  noted  [see  under  Case  528]  that 
the  French  military  authorities  do  not  allow  the  use  of 
hypnotism  in  the  army.)  With  respect  to  the  present  case 
(530)  >  oi  course,  the  French  observers  would  not  deny  the 
power  of  hypnotism  to  produce  the  cure.  Babinski  and 
Froment's  Postscript  to  the  English  edition  of  their  work  on 
hysteria,  remarks  that,  though  Roussy  and  Lhermitte  state 
that  vasomotor  symptoms  may  disappear  along  with  the 
psychotherapeutic  cure  of  paralyses  and  contractures,  yet 
Roussy  and  Boisseau  later  admitted  that  improvement  in 
thermal  and  vasomotor  control  is  at  best  an  exceedingly 
slow  one. 

More  recent  personal  communications  indicate  that  there 
is  still  room  for  some  question  as  to  the  curability  by  sugges- 
tion of  such  disorders  as  tic,  tremor,  vasomotor  imbalance, 
and  the  like.  In  short,  the  true  scope  of  the  "pithiatic" 
or  suggestion- curable  diseases  is  still  somewhat  a  matter  of 
controversy. 


744  TREATMENT  AND  RESULTS 


Shell-shock:  "Doll's  head"  anesthesia,  mutism 
Hypnosis. 


Case  531.     (NoNNE,  December,  1915.) 

An  officer,  mute  for  five  months  following  shell-shock,  had 
been  for  four  months  treated  in  a  succession  of  hospitals  — 
field  hospital,  war  hospital,  two  reserve  hospitals. 

He  had  no  acquired  or  hereditary  neuropathic  taint,  but 
even  in  the  period  before  the  critical  shock  he  had  been  under 
tremendous  physical  and  mental  strain.  The  explosion 
produced  a  total  anesthesia  of  the  skin  of  the  head,  face, 
neck  and  shoulder  region  —  in  short,  what  Charcot  called 
the  "  doll's  head  "  form  of  sensory  disorder.  Moreover, 
there  was  a  marked  contraction  of  the  visual  fields. 

The  patient,  when  treatment  was  given,  fell  at  once  into  a 
deep  hypnosis  and  began  to  intone,  and  then  to  speak  iso- 
lated words,  and  finally  to  speak  complete  sentences.  All 
that  was  left  of  his  mutism  was  a  slight  over-fatiguability  of 
the  speech  organs.  This  also  cleared  up  in  the  next  few  days. 
He  was  discharged  well,  and  had  already  been  —  December, 
1915  —  some  months  in  the  field. 

Case  531,  though  an  officer,  responded  to  hypnosis  well, 
and  Nonne  remarks  that  hypnotizability  is  independent  of 
the  presence  of  any  neuropathic  tendencies,  or  of  any  loss 
of  resistance  through  exhaustion.  One  trouble  with  the  hyp- 
notic method,  according  to  Nonne,  is  the  fatigue  of  the 
hypnotizer  and  his  inability  to  rely  upon  assistants. 

Re  Charcot,  Nonne  remarks  that  the  work  of  Charcot  on 
hysteria  is  not  sufficiently  well-known,  especially  as  clviUan 
practitioners  in  peace  times  had  few  cases.  Re  taint,  Nonne 
found  such  tendencies  absent  in  more  than  half  of  his  cases 
with  careful  anamneses.  The  absence  of  adequate  psycho- 
genic cause  is  a  not  uncommon  experience  according  to 
Nonne.  Nonne,  finding  26  cases  of  pure  neurosis  amongst 
1800  cases  of  war  injury,  had  a  considerable  number  of  odd 
erroneous  diagnoses  in  the  group.  Not  only  were  cerebro- 
spinal paralyses  wrongly  diagnosticated,  but  ischemic  paraly- 
sis, plexus  paralysis,  arthritis  deformans  and  synovitis. 


TREATMENT  AND  RESULTS  745 


A  soldier  is  put  in  the  Landsturm  at  22  and  later 
called  "unfit"  by  reason  of  tremors  after  mine- 
explosion  (history  of  tremors  at  14  after  a  fall),  but 
is  cured  by  hypnosis. 


Case  532.     (Grunbaum,  November,  1916.) 

A  Landsturm  soldier,  22  (father  excitable,  family  other- 
wise normal),  had  a  history  of  being  the  best  scholar  in  the 
class  and  well  up  to  his  fourteenth  year.  At  16  he  fell  from 
a  tree  and  though  he  apparently  sustained  no  injury  his  head 
and  arm  began  to  tremble.  He  became  unable  to  learn  and 
gave  up  his  preparations  to  be  a  teacher.  The  tremor, 
however,  disappeared  in  six  months  and  he  went  into  some 
technical  work.  At  16^  years  he  went  as  cabin-boy,  but  in 
a  fortnight  he  was  sent  home  by  the  physician.  He  then 
began  to  breed  carrier  pigeons  and  got  first  prizes  at  inter- 
national exhibitions.  He  also  went  into  foundry  work  and 
did  well  as  an  apprentice.  He  worked  well  at  home  and 
busied  himself  with  setting  up  small  electrical  and  other  ma- 
chines. He  had  never  been  interested  in  women  and  loved 
his  pigeons  best,  and  therefore  was  regarded  by  people  who 
knew  him  as  not  quite  right.     He  was  also  non-alcoholic. 

After  mobilization  he  was  sent  back  twice  but  finally  was 
put  into  a  Jdger  Battalion.  After  reaching  the  front  he  had 
to  have  a  hernia  operation  and  on  getting  well  went  back  to 
his  place  and  a  few  days  later  a  mine  exploded  near  him.  He 
was  much  frightened  and  fell  down  unconscious.  On  re- 
gaining consciousness  he  felt  a  "  running  "  in  the  legs  and 
tremors  In  the  hands.  The  latter  grew  stronger  and  began 
to  affect  the  arms. 

After  two  months  in  hospital  he  went  to  garrison  unre- 
covered,  was  placed  in  the  Landsturm  and  did  four  months 
station  duty  In  Russia.  The  tremors  persisted  and  when  his 
comrades  played  a  bad  practical  joke  on  him  the  tremors  got 
so  bad  that  he  was  sent  back  home  as  unfit  for  service. 

He  was  a  stocky  looking,  well-nourished  man  of  middle 
height,  without  visceral  disease  or  sign  of  organic  nervous  dis- 


746  TREATMENT  AND  RESULTS 

order.  The  shaking  tremor  grew  much  more  powerful  in 
any  state  of  excitement  but  always  paused  sufficiently  to 
permit  the  execution  of  any  particular  movement.  The  head 
movements  were  continuous,  slight  rotations.  There  were  a 
few  regions  of  anesthesia  to  touch,  but  these  areas  differed  at 
different  examinations.  There  was  a  general  hyperesthesia. 
Conjunctival,  corneal  and  pharyngeal  reflexes  were  absent. 
The  man  was  slightly  excitable,  apprehensive,  depressed, 
complained  of  sleeping  badly,  did  not  want  to  sit  or  stand  and 
felt  as  if  he  wanted  to  run  away,  no  matter  where.  In  drop- 
ping off  to  sleep  he  would  fall  out  of  bed  and  talked  aloud  in 
his  sleep.  He  thought  he  was  incurably  sick.  Intelligence 
and  school  knowledge  were  very  good. 

He  was  hypnotized  eight  times  for  periods  of  about  five 
minutes  each.  Hypnosis  was  extremely  easy  to  accomplish. 
At  the  second  trial  the  manual  tremor  disappeared.  After 
the  third  trial  there  was  an  essential  improvement  in  the 
shaking  tremor.  Moreover,  his  emotional  state  had  become 
happier.  He  began  to  sleep  well.  He  was  now  free  from 
disease  and  regained  confidence  and  looked  upon  himself 
as  well  and  fit  for  work.  Undoubtedly  without  hypnotism 
this  man  would  have  been  released  from  service  after  a  few 
months  of  inconsequential  hospital  care  without  pension. 

Re  tremors,  see  remarks  under  Case  308,  concerning  the 
possibly  organic  nature  of  many  of  the  so-called  Shell-shock 
tremors;  an  opinion  apparently  shared  in  by  Meige  and  by 
Guillain.  Bablnski  also  found  that  these  tremors  were  not 
influencible  by  psychotherapy.  Yet  here  is  an  instance  in 
which  tremors  are  reported  cured  by  hypnosis,  and  more- 
over, tremors  that  were  recurrent  from  an  ante-bellum  at- 
tack at  14.     See  remarks  under  Case  530. 


TREATMENT  AND  RESULTS  747 


Shell-shock,    slight  injury,   unconsciousness:    As- 
tasia-abasia :  Recovery  under  hypnosis,  two  seances. 


Case  533.     (NoNNE,  December,  1915.) 

A  musketeer,  without  neuropathic  taint  and  without  ner- 
vous symptoms  before  the  war  (parents  both  dead  of  tuber- 
culosis, eleven  brothers  and  sisters  died  young),  saw  four 
comrades  killed  by  a  shell  October  27,  1914.  The  musketeer 
himself  was  slightly  Injured  superficially  In  the  back.  He 
remained  unconscious  for  three  hours  and  on  coming  out 
showed  general  tremor  of  the  body,  felt  pressure  In  the  head, 
was  lachrymose  and  unable  to  walk  or  stand.  He  was  sub- 
ject to  Insomnia.  He  was  In  four  different  hospitals,  finally 
reaching  Eppendorf .  Diagnosis  rendered  at  the  first  hospital 
and  carried  on  through  the  others  was  hemorrhage  into  the 
spinal  canal. 

For  two  months  at  Eppendorf  he  lay  In  extension.  He 
was  then  examined  by  Nonne,  who  found  general  neuro- 
pathic habitus,  pronounced  "  cramp  neurosis  "  in  the  lower 
extremities,  psychogenic  astasla-abasia,  hyperldrosis  of  the 
lower  extremities,  marked  cyanosis  of  feet  and  lower  legs, 
increased  tendon  and  skin  reflexes,  pseudoclonus,  no  Bablnski 
or  Oppenheim  reflexes.  The  man  complained  of  pressure 
in  the  head,  sleeplessness,  a  feeling  of  depression  and  hope- 
lessness.    Pulse  120-130. 

Hypnosis  proved  easy.  After  the  first  treatment  the  man 
stood  and  walked  and  showed  no  tremor.  The  next  day  the 
hypnosis  was  repeated  and  the  cyanosis  of  the  legs  dis- 
appeared. Sleep  on  the  second  night  was  good.  Appetite 
returned  and  the  man  fell  Into  a  good  emotional  state. 
Thereafter  the  patient  was  intentionally  ignored  by  the 
physicians  and  could  soon  not  be  distinguished  in  any  re- 
spect from  the  other  non-nervous  convalescents. 

This  case  Is  expressly  stated  by  Nonne  to  resemble  in  all 
respects  those  formerly  described  by  Oppenheim  as  "  trau- 
matic neurosis." 


748  TREATMENT  AND   RESULTS 


Crural  monoplegia:   Cured  by  hypnosis. 


Case  534.     (Hurst,  1917.) 

A  Belgian  soldier  fell  into  mud  on  the  collapse  of  a  roof 
from  which  he  was  observing  the  enemy.  It  was  an  hour 
before  he  got  his  left  leg  out  of  the  mud,  and  found  it  fixed 
in  extension.  He  was  sent  to  England,  where  for  three 
months  the  leg  remained  stiff.  The  spastic  paralysis  did  not 
seem  organic  as  the  leg  was  dragged  behind.  The  knee  and 
ankle  could  be  bent  only  by  using  much  force.  The  entire 
leg  was  in  all  ways  anesthetic.  Babinski  sign  gave  additional 
proof  that  the  condition  was  hysterical :  when  the  patient  lay 
with  arms  folded  and  legs  apart  and  then  tried  to  sit  up,  the 
normal  leg  was  lifted  and  the  paralyzed  leg  remained  fiat. 

According  to  Hurst,  the  paralysis  and  stiffness  were  due 
to  an  autosuggestion  from  the  legs  being  embedded  in  mud. 
The  anesthesia  was  probably  a  matter  of  medical  suggestion 
produced  in  the  course  of  examination  during  the  three 
months  of  disability.  According  to  Hurst,  Babinski  is  right 
in  supposing  that  hysterical  anesthesia  is  almost  invariably 
produced  by  the  observer. 

Accordingly  a  strong  faradic  current  was  passed  through 
the  leg,  and  he  was  assured  that  sensation  and  power  would 
be  restored.  However,  he  could  still  walk  only  with  diffi- 
culty. 

Hypnosis  was  therefore  resorted  to  and  repeated  on  several 
occasions.  He  went  back  to  duty  in  three  weeks,  although  he 
still  held  the  leg  somewhat  stiff  when  he  walked. 

Re  recurrences  after  hypnotism,  see  remarks  of  Nonne 
under  Case  530.  Howland  also  notes  that  cases  treated  by 
hypnotism  must  be  followed  up  to  prevent  relapse.  In  the 
above  case  of  Hurst's,  it  will  be  noted  that  the  hypnotic 
treatment  was  several  times  repeated. 


TREATMENT  AND   RESULTS  749 


Shell-shock,  emotional  (slight  trauma) :  Tremors 
and  sensory  impairment :  Cure  by  hypnosis,  thrice 
repeated. 


Case  535.     (NoNNE,  December,  1915.) 

A  reservist,  always  well,  not  neuropathic  (mother  had  had 
seizures,  possibly  epileptic,  for  many  years)  was  wounded  in 
the  left  calf  by  a  shell  fragment,  about  the  middle  of  Decem- 
ber, 1 9 14.  He  was  at  the  same  time,  as  a  result  of  the  shell 
explosions  near  by,  afflicted  with  a  tremor  of  the  whole  body ; 
this  tremor  gradually  increased  and  proved  refactory  to  all 
treatment  for  nine  months. 

At  the  beginning  of  September,  191 5,  the  patient  reached 
Nonne's  wards,  showing  tremor  of  head,  arms  and  legs, 
with  pronounced  hypalgesia  of  the  whole  body,  abolition  of 
frontal  and  conjunctival  reflexes,  and  contraction  of  the 
visual  fields. 

The  tremor  of  the  head  was  completely  removed  at  the 
first  hypnotic  treatment.  There  was  a  slight  recurrence  of 
this  tremor  two  days  later,  and  traces  of  it  could  be  observed 
for  nine  days.  A  third  hypnotic  treatment  sw^ept  away  this 
tremor,  which  did  not  return. 

The  patient  was  discharged  after  about  four  weeks,  suit- 
able for  garrison  duty. 

Re  traumatic  neurosis,  Nonne  dislikes  this  term  of  Oppen- 
heim,  because  such  a  term  rather  tends  to  connote  unfavor- 
able prognosis.  As  quoted  under  Case  530,  Nonne  holds 
that  the  war  data  show  that  hysteria  is  neither  a  form  of 
degeneration  nor  an  affair  built  on  the  Freudian  schema. 

Nonne  in  fact  maintains  that  the  hysterical  syndrome  may 
occasionally  occur  with  much  greater  ease  in  a  normal  per- 
son than  ever  has  been  known  before.  It  is  precisely  in  these 
cases  of  normals  getting  hysterical  that  Nonne  gets  espe- 
cially good  results  with  hypnosis.  If  the  development  of 
the  hysterical  syndrome  had  extended  over  days  or  weeks, 
then  the  hypnotic  cure  was  a  slower  one.  The  above  re- 
servist developed  his  Shell-shock  gradually  and  required  three 


750  TREATMENT  AND   RESULTS 

hypnotic  treatments.  But  although  the  number  of  doses  of 
hypnotism  required  may  be  said  roughly  to  depend  upon 
the  time  which  the  condition  took  to  come  to  a  head,  yet 
there  is  no  similar  rule  re  duration.  A  miracle  cure  may  be 
brought  about  even  in  cases  that  have  lasted  over  a  year. 
This  result,  if  confirmed,  would  signify  that  the  hysterical 
condition  once  fixated  did  not  especially  increase  in  its 
tenacity. 

Re  hypnosis  in  Germany,  it  should  be  noted  that  Nonne 
is  the  chief  protagonist  for  hypnosis,  at  least  among  the 
well-known  neurologists.  Psychoelectric  cures,  which  the 
Germans  term  Kaufmann's  cure,  are  also  greatly  in  vogue  in 
German  clinics.  Despite  the  well-based  claims  of  Lt.-Col. 
Myers  and  of  Eder,  some  English  observers  appear  to  con- 
demn hypnosis  as  inadequate,  or  even  as  dangerous. 

A  series  of  relatively  successful  cases  like  those  here  men- 
tioned might  yield  a  wrong  impression  of  the  value  of  hyp- 
nosis (see  Felling's  unsuccessful  case  369). 


TREATMENT   AND   RESULTS  75 1 


Hysterical  paraplegia  of  gradual  development:  re- 
covery only  under  repeated  hypnosis. 


Case  536.     (NoNNE,  December,  191 5.) 

A  volunteer,  of  nervous  parents,  had  for  four  years  suf- 
fered from  attacks  of  uncertain  (hysterical  or  epileptic)  nature. 
These  attacks  came  on  again  after  strenuous  marching 
in  the  campaign  in  Belgium  and  France.  Released  from 
service  at  the  front  and  detailed  for  guide  duty,  he  proved 
unsuitable  for  this  work,  too,  and  was  sent  back  to  a  hospital 
at  home.  Here  there  gradually  developed  a  paralysis  of  the 
lower  extremities.     Treatment  proved  ineffective. 

At  the  end  of  January,  19 15,  he  came  to  Nonne's  wards 
at  Eppendorf  with  a  paralysis  that  had  lasted  six  months. 
There  was  a  total  paraplegia  inferior,  with  anesthesia  for  all 
sensation  from  the  knees  downward.  The  lower  legs  and 
feet  were  cyanotic  and  cold.  The  tendon  and  skin  reflexes 
were  lively.  There  was  a  moderate  contraction  of  the  visual 
fields  on  both  sides. 

Under  hypnosis,  the  patient  proved  able  to  move  both 
joints  somewhat,  but  very  weakly  and  slowly.  The  patient 
was  hypnotized  daily  for  a  week,  and  made  slow  progress. 
Only  after  another  week  did  it  prove  possible  to  get  him  to 
stand.  After  four  weeks,  his  gait  had  so  improved  as  to  look 
like  that  of  a  tired  old  man.  Three  weeks  more  of  treat- 
ment permitted  the  patient  to  walk,  run  and  hop  normally. 
Repeated  waking  suggestion  had  failed  to  accomplish  anything 
in  this  case.  The  improvement  followed  only  hypnosis.  It 
seems  to  be  a  general  principle  that  in  cases  of  gradual  de- 
velopment, the  recovery  by  hypnosis  will  also  be  gradual. 

Re  repeated  hypnosis  for  cases  of  gradual  development, 
see  remarks  under  the  preceding  case  (535). 


752  TREATMENT  AND  RESULTS 


Struck  by  rifle  butt:  blindness  of  an  eye  already 
poor.     SheU-shock :   dysbasia.     Hypnosis. 


Case  537.     (ORxMOND,  May,  1915.) 

A  lieutenant,  20  years,  managed  to  get  into  the  army 
despite  the  fact  that  he  had  never  been  able  to  use  his  left 
,eye,  owing  to  hypermetropia  and  amblyopia.  He  was  hit  on 
the  left  side  of  the  head  by  a  rifle  butt,  and  knocked  uncon- 
scious, in  June.  On  recovering,  he  found  he  could  not  see  at 
all  with  his  left  eye,  which  he  had  never  been  in  the  habit  of 
using.  August  10,  he  was  wounded  slightly  in  the  left  thigh. 
August  23,  while  still  on  duty,  with  the  wound  not  com- 
pletely healed,  he  was  blown  up  by  a  shell.  He  regained 
consciousness  on  a  stretcher.  Feeling  the  pain  in  his  old 
wound,  he  thought  he  should  be  unable  to  walk. 

On  shipboard,  he  found  that  he  actually  could  not  walk. 
He  kept  his  left  eye  covered  by  a  shade  on  account  of  head- 
ache that  would  follow  exposure  to  light.  He  was  much 
excited  and  had  bad  nightmares. 

After  the  journey  home  from  the  Dardanelles,  it  was  found 
that  the  left  eye  was  normal  except  for  the  hypermetropia, 
despite  the  fact  that  he  was  quite  unable  to  see  with  the  eye. 

He  was  hypnotized  four  times,  losing  the  nightmares  and 
much  of  the  headache  after  the  first  treatment;  the  eye  pain 
on  exposure  to  light,  after  the  second  treatment;  and  the 
blindness,  after  the  third  treatment.  He  was  now  able  to 
see  with  his  left  eye  as  well  as  before  he  was  struck.  He  was 
still  unable  to  walk  without  crutches.  Hypnotized  the  fourth 
time,  he  was  told  he  could  walk,  and  did  so. 

For  hypnotic  treatment  of  blindness,  see  under  Case  521, 
Re  blindness  of  eye  already  poor,  see  Cases  294-301  (296  and 
297  eye  cases).  Ormond  states  that  in  the  treatment  of 
Shell-shock  blindness,  he  first  tried  rest,  tonics,  cutting  off 
tobacco,  confinement  in  bed,  isolation,  persuasion,  encourage- 
ment, counter-irritation;  but  that  all  these  measures  failed. 
Suggestion   and   hypnosis   succeeded. 


TREATMENT   AND   RESULTS  753 


Shell  explosion ;  concussion ;  retinal  hemorrhage : 
Blindness.     Cure  by  hypnosis. 


Case  538.     (Hurst,  November,  191 6.) 

An  English  private,  22,  was  looking  over  a  parapet,  July 
18,  19 1 5.  He  afterward  remembered  sand  thrown  in  his 
eyes  [and  a  fall  backward,  hitting  his  head,  after  a  shell  had 
struck  the  sandbags  in  front  of  him.  He  was  unconscious 
24  hours.  Upon  recovery,  he  found  himself  completely  blind, 
save  that  he  could  just  tell  light  from  darkness  with  the  left 
eye.  His  eyes  were  sore  and  eyelids  blackened;  there  was 
also  severe  headache  and  partial  deafness. 

Hearing  returned  and  the  headache  improved  shortly;  but 
the  condition  of  the  eye  seemed  more  permanent.  On 
forcibly  opening  the  eyes,  September  14,  they  were  turned 
far  upwards  so  that  the  iris  could  scarcely  be  seen.  Some 
sand  grains  were  buried  in  the  conjunctiva,  not  in  the  cor- 
nea.    There  was  no  inflammation  about  the  sand  grains. 

In  hypnosis,  he  was  told  that  he  would  see  on  waking. 
The  moment  he  woke,  this  suggestion  was  repeated  forcibly 
and  his  eyes  were  held  open.  He  cried  out  that  he  could  see; 
tears  ran  down  his  cheeks;  he  fell  on  his  knees  in  gratitude. 
Three  days  later,  he  said  he  was  able  to  see  as  well  as  he  had 
ever  seen.  There  was,  however,  an  opacity  of  the  vitreous 
of  the  left  eye,  the  result  of  a  retinal  hemorrhage:  doubtless 
the  result  of  injury  at  the  time  of  the  explosion.  September 
30,  he  had  perfect  vision  in  the  right  eye  and  6/36  in  his  left. 

Re  results  of  hypnotic  treatment,  Lt.-Col.  Myers,  sum- 
marizing 23  cases  of  Shell-shock,  got  apparently  complete 
cures  in  26  per  cent,  and  distinct  improvement  in  another 
26  per  cent.  He  failed  to  hypnotize  35  per  cent,  and  got 
no  improvement  after  hypnosis  in  13  per  cent.  Is  the  re- 
covery after  hypnosis  complete  and  permanent?  Lt.-Col. 
Myers  believes  that  it  may  be,  but  others  remark  the  tend- 
ency to  relapse  (see  Case  534).  Similar  objections  may 
be  made  to  the  psychoelectric  treatment  as  used  by  Vincent, 
Yealland,  or  Kaufmann.     See  under  Case  535. 


754  TREATMENT   AND   RESULTS 


Appendix   operation:    Post-operative    retention   of 
urine.     Relief  by  hypnosis. 


Case  539.     (PoDiAPOLSKY,  August,  191 7.) 

A  soldier,  32,  operated  for  appendicitis,  had  a  post-opera- 
tive retention  of  urine.  Hypnotic  suggestion  was  requested 
to  reestablish  excretion  of  urine  before  resort  should  be  had 
to  the  catheter. 

Somnambulistic  amnesia  was  obtained  at  once  and  with- 
out questioning  him  P.  suggested  to  him  directly  that  he 
must  feel  the  need  of  micturition.  The  suggestion  was  un- 
successful. However,  bearing  in  mind  psychogenic  obstacles 
of  an  unknown  nature,  P.  questioned  the  patient  as  to  sensa- 
tions and  learned  that  in  the  operation  the  skin  had  been 
burned  about  the  urinary  passage  and  that  the  patient 
feared  micturition.  Besides  this,  micturition  was  painful  on 
account  of  the  wound  above  the  appendix.  The  patient  also 
feared  that  the  sutures  would  yield. 

Accordingly  assurance  was  given  that  the  burned  parts 
would  be  insensible  and  that  the  bladder  could  be  emptied 
without  effort  and  without  endangering  the  sutures.  Anal- 
gesia was  produced  by  a  few  passages  of  the  hand  upon  the 
bed  clothes.  Complying  with  post-hypnotic  suggestion  the 
patient  urinated  after  a  quarter  of  an]  hour  of  sleep,  and  In 
thirty-six  hours  retention  was  relieved. 

With  respect  to  frequency  of  Immediate  somnambulism  for 
the  first  trial,  P.  states  that,  although  authorities  set  the 
percentage  of  successful  Immediate  somnambulisms  at  17-20 
per  cent,  war  conditions  yield  three  or  four  times  as  high  a 
percentage.  The  war  has  produced  a  suitable  soil  for  hyp- 
notism. Hypnosis  is  impossible  In  from  i^  to  2  per  cent  of 
cases. 


TREATMENT  AND  RESULTS  755 


Wound  of   sciatic   nerve:    Pains   after  operation. 
Relief  by  hypnosis. 


Case  540.     (PoDiAPOLSKY,  August,  191 7.) 

A  German  prisoner,  33,  was  admitted  to  a  Russian  Hos- 
pital, November  11,  1916,  with  "a  bad  wound  of  upper  right 
thigh,  marked  pains  in  right  sciatic  nerve  especially  affect- 
ing feet."  Morphine  and  pantopon  did  not  abolish  the  pain. 
Insomnia.  November  13,  the  sciatic  nerve  was  surgically 
freed  from  a  scar  and  laid  in  the  midst  of  the  femoral  biceps. 
Every  evening  pantopon  was  injected;  but  the  pains  and 
insomnia  persisted  nevertheless. 

November  19,  he  was  hypnotized.  The  pain  stopped. 
He  had  an  excellent  night,  and  the  next  day  felt  only  a  slight 
pain  in  the  toes. 

Curiously  enough,  while  giving  him  suggestion  in  the  Ger- 
man language,  P.  had  said  fingers  instead  of  toes  (inadvert- 
ently, since  the  Russian  language  uses  the  same  term  for 
both).  He  slept  well  to  November  29  but  still  felt  a  slight 
pain  in  the  toes.  On  November  29  another  hypnotic  sitting 
was  given,  and  the  toes  this  time  were  named  correctly. 
The  next  day  the  patient  said,  "You  have  relieved  me  of  all 
the  rest  of  my  pain."  He  had  no  pain  thereafter  and  the 
morphine  and  pantopon  were  dispensed  with.  Sleep  re- 
turned. 

Incidentally,  this  patient  had  his  hair  grow  white  in  a  few 
months  of  war. 


756  TREATMENT  AND  RESULTS 


Ship  blown  up  by  mine :  Stereotyped  explosion 
dream  by  survivor:  Cure  by  hypnosis  (also  of 
antebellum  habitual  headache). 


Case  541.     (RiGGALL,  April,  1917.) 

A  survivor  of  H.M.S.  T.B.  11,  blown  up  by  a  mine  off 
Harwich,  was  admitted  to  the  naval  hospital  at  Chatham, 
March  3,  191 6,  a  well-nourished,  nervous  looking  lad,  aged 
20.  After  the  accident,  he  began  to  dream,  always  the  same 
dream,  of  the  explosion,  waking  up  with  the  cry  of  the  ship 
mates,  and  then  unable  to  sleep  the  rest  of  the  night.  The 
knee  and  ankle- jerks  were  somewhat  exaggerated. 

April  15,  when  there  had  been  no  improvement,  he  was 
hypnotized.  The  patient  was  told  to  lie  back  in  an  arm 
chair,  make  himself  comfortable  and  allow  muscles  to  relax. 
He  was  told  to  fix  his  eyes  and  concentrate  his  attention  on 
an  electric  lamp.  The  suggestion  of  sleep  was  made,  and  he 
was  repeatedly  told  in  a  monotonous  voice  that  he  was  be- 
coming more  and  more  sleepy.  Then  in  an  emphatic  voice 
he  was  told  that  the  treatment  would  completely  cure  him. 
He  had  no  more  dreams  after  this  first  sitting. 

Hypnosis  was  continued  every  other  day  until  April  20, 
when  he  was  discharged  cured.  After  the  first  sitting  hyp- 
nosis was  Induced  by  simply  telling  the  patient  to  go  to  sleep, 
which  he  would  immediately  do  on  entering  the  room,  while 
still  standing  up.  At  subsequent  sittings,  he  was  made  to 
write  twenty  times  such  phrases  as:  "I  feel  much  better"; 
"  If  shall  have  no  more  bad  dreams." 

Once  when  a  tooth  was  to  be  pulled  a  post-hypnotic  sug- 
gestion that  no  more  pain  would  be  felt  was  given,  nor  was  any 
pain  felt.  Headache  persisted  after  the  first  two  or  three 
sittings.  Accordingly,  during  hypnosis  a;  pencil  was"^  pressed 
to  the  forehead  with  the  suggestion  that  it  would  burn  and 
that  after  waking  there  would  be  an  itching  pain  for  half 
an  hour,  followed  by  recovery  from  headache.  Curiously 
enough,  a  distinct  erythema  of  the  skin  was  observed  over 
the  point  of  pressure.     Toothache  and  headache  vanished. 


TREATMENT  AND   RESULTS  757 


Shell-shock  from  air-craft  bomb:  Amnesia:  Re- 
covery under  hypnosis  (also  removal  of  a  headache 
dating  from  childhood). 


Case  542.     (BuRMiSTON,  January,  1917.) 

May  22,  1916,  a  stoker,  26,  was  found  on  shipboard  in  a 
workshop  behind  oil  drums,  refusing  to  come  out,  looking 
dazed,  not  recognizing  messmates,  suspicious  and  complain- 
ing of  headache.  He  reached  the  Royal  Naval  Hospital  at 
St.  Malo,  May  24,  answering  questions  "Don't  know,"  and 
physically  normal  except  for  diminished  knee-jerks.  At  the 
end  of  two  or  three  weeks  he  would  answer  questions  about 
his  stay  at  the  hospital,  but  complained  of  headache  or 
weight  in  the  head.     Wassermann  reaction,  negative. 

Special  examination  on  May  26,  showed  an  amnesia  for 
everything  up  to  his  arrival  at  St.  Malo.  For  example,  he 
did  not  know  the  name  or  use  of  a  hammer  or  a  pressure 
gauge,  though  he  knew  the  pressure  gauge  was  made  of  brass 
and  glass,  having  seen  brass  and  glass  in  the  hospital  wards. 
He  had  no  idea  of  the  nature  of  a  ship.  He  was  sent  to  the 
sick  bay  at  the  Royal  Naval  Barracks  at  Chatham,  July  7, 
carrying  a  recommendation  that  he  be  retrained  as  a  stoker. 

He  w^as  put  under  hypnosis,  induced  by  gazing  at  the  brass 
knob  of  a  paper  weight.  He  went  off  easily,  was  told  there 
was  nothing  to  worry  about,  taken  back  to  the  beginning 
of  his  illness,  and  asked  what  happened.  He  told  about 
a  bomb  explosion  from  aircraft,  and  how  he  had  lost  his 
memory  after  a  nearby  explosion.  He  told  how  he  was 
married  and  had  a  child  21  months  old.  During  the  nar- 
rative about  bombs  falling,  his  worry  was  such  that  he  was 
put  in  a  deeper  hypnotic  sleep,  and  was  told  that  he  would 
remember  all  that  had  happened.  Upon  being  ordered  to 
wake  up,  he  remained  dazed  for  a  few  moments,  and  then 
said  that  he  was  all  right.  Asked  about  his  marriage,  he 
replied  that  of  course  he  was  married  and  had  a  child. 

After  four  days  leave,  he  returned,  July  13,  without  trouble 
except  a  headache,  from  which  it  appeared  that  he  had  suf- 


758  TREATMENT  AND   RESULTS 

fered  ever  since  a  fall  when  a  child.  He  was  again  put  into 
a  hypnotic  state  and  asked  to  remember  the  accident  that 
caused  the  headache.  He  was  conducted  back  through  the 
years,  and  finally  described  a  white  house  in  India,  his  fall  in 
the  area,  the  black  people  in  white  clothes,  the  cut  bleeding 
head.  He  was  told  that  he  would  have  no  more  of  such 
headaches.  On  being  wakened,  he  said  that  his  headache 
was  gone,  and  retold  the  story  of  the  accident.  August  2, 
he  said  he  had  never  felt  better  in  his  life.  September  I,  he 
was  drafted  to  a  seagoing  ship. 


TREATMENT  AND   RESULTS  759 


Shell-shock,  unconsciousness:  Convulsions  (recol- 
lection of  childhood  convulsions) :  Cure  by  hyp- 
nosis. 


Case  543.     (Hurst,  March,  1917  ) 

A  New  Zealander  was  rendered  unconscious  for  a  few 
minutes  following  concussion  from  a  high  explosive  shell. 
Convulsions  developed,  occurring  at  least  once  and  often 
several  times  a  day. 

As  to  the  origin  of  these  convulsions,  it  appeared  that  the 
soldier  had  had  a  few  convulsions  after  falling  on  his  head  at 
the  age  of  8.  According  to  Hurst,  recollection  of  these 
childhood  convulsions  probably  led  by  a  process  of  autosug- 
gestion to  the  Shell-shock  convulsions. 

Captain  Crabtree  hypnotized  the  man,  suggesting  recov- 
ery.    The  fits  immediately  ceased  and  did  not  recur. 


Recurrent  hysterical  mutism.  Spontaneous  recov- 
ery in  {a)  18  months  (antebellum  incident),  {h) 
Hypnotic  recovery  in  a  few  minutes. 


Case  544.     (Eder,  August,  191 6.) 

A  soldier  in  a  mine  accident  eight  years  before  the  war, 
lost  his  speech  when  his  brother  was  killed,  and  then  re- 
covered his  speech  spontaneously  after  18  months. 

After  a  shell  explosion  in  Gallipoli,  he  was  again  struck 
speechless  and  also  deaf. 

Six  weeks  later,  he  came  to  Dr.  Eder  and  objected  in  writing 
to  treatment,  saying  that  he  believed  in  nature's  methods. 
God  had  taken  his  voice  away  before  and  had  restored  it. 
Eder  replied  In  writing  "  rather  irreverently  "  that  God  had 
taken  18  months,  but  he  could  do  it  in  a  few  minutes.  The 
patient  afterward  consented  to  treatment,  and  speech  and 
hearing  w^ere  duly  restored  in  the  time  promised,  whereupon 
Dr.  Eder  told  him  that  in  point  of  fact  his  physician  was 
merely  the  instrument  of  Providence. 


760  TREATMENT  AND  RESULTS 


Neurasthenic  symptoms:  Cured  by  repeated  hyp- 
nosis. 


Case  545.     (ToMBLESON,  September,  191 7.) 

A  private,  24,  was  admitted  to  hospital  with  diagnosis 
neurasthenia,  March  11,  1916.  He  suffered  from  vertical 
headache;  general  analgesia,  more  definite  on  the  right  side 
(patient  left-handed) ;  loss  of  smell  and  taste,  also  more 
definite  on  the  right  side ;  paresis  of  right  leg,  with  dragging  of 
foot  (old  trench  foot) ;   and  sleeplessness. 

The  next  day  Tombleson  put  him  in  a  hypnotic  state,  third 
stage,  and  again,  March  13,  but  without  results. 

IMarch  14,  the  somnambulistic  stage  was  reached  in  hyp- 
nosis, and  next  day  the  man's  headache  was  much  relieved  as 
a  result  of  the  suggestion  offered.  He  was  again  hypnotized 
and  the  following  day,  March  16,  the  headache  had  vanished 
and  the  man  was  in  general  much  improved.  In  somnambu- 
lism the  disappearance  of  the  analgesia  was  suggested,  and  it 
proved  possible  to  make  the  man  walk  about  without  limp 
and  without  dragging  the  right  foot.  Next  day  the  anal- 
gesia was  much  relieved.  In  somnambulism  the  suggestions 
were  repeated. 

March  18,  the  man  said  he  was  quite  well,  and  proved  to  be 
so  on  examination,  except  that  he  could  not  yet  taste  with 
absolute  normality  on  the  right  side.  In  somnambulism  it 
was  further  suggested  that  the  cure  was  a  perfect  one  and 
included  the  sense  of  taste.  However,  March  25,  the  ex- 
pected improvement  had  not  yet  occurred  in  the  taste, 
whereupon  further  suggestions  were  given  in  hypnotic  som- 
nambulism, re  taste.     Next  day  taste  had  become  normal. 

Ke  hypnosis,  Tombleson  says  that  the  most  successful 
cases  of  hypnosis  are  those  of  Shell-shock  psychasthenia,  but 
that  he  gets  very  good  results  with  hyperthyroidism  and 
with  neurasthenia  also.  He  goes  so  far  as  to  say  that  prac- 
tically all  cases  of  war  neurasthenia  and  psychasthenia  can 
be  cured  and  sent  back  to  work  if  treatment  by  hypnotic 
suggestion  is  used  in  a  reasonable  time. 


TREATMENT   AND    RTZISULTS  '  761 


Neurotic  symptoms :  Im.provemient  under  repeated 
hypnosis. 


Case  546.  (TOMBLESON,  September,  1917.) 
A  private,  32,  was  admitted,  April  15,  1916,  to  Tombleson's 
ward  from  the  Cottonera  Mental  Ward  with  the  diagnosis: 
psychasthenia  with  paresis  of  right  arm.  The  man  was  very 
suspicious  of  the  medical  profession,  melancholy,  morose  and 
prone  to  tears.  He  had  been  kicked  by  a  horse  four  years 
before  and  showed  a  depressed  and  very  tender  scar  in  the 
right  parietal  region.  The  right  side  of  the  body  since  that 
injury  had  been  getting  weaker,  but  the  arm  was  much 
weaker  than  the  leg.  Anesthesia  was  practically  complete 
on  the  right  side.  There  was  a  wasting  of  the  muscles  of 
the  right  arm  and  the  skin  of  the  hand  and  fingers  was  thin 
and  shiny. 

Before  his  transfer  the  man  was  placed  in  the  somnambu- 
listic state,  with  suggestions  of  happiness  and  confidence  In  the 
coming  cure.  He  arrived  at  Valletta,  April  16,  In  a  cheerful 
frame  of  mind,  stating  that  there  was  nothing  now  the  matter 
but  weakness.  Under  somnambulism  the  loss  of  symptoms 
was  suggested  and,  April  17,  the  patient  was  well  except  for  the 
loss  of  power  in  the  arm  and  leg.  Dally  training  under  som- 
nambulism was  given  for  a  period  of  seven  days,  with  sug- 
gestions especially  leveled  at  the  paretic  muscles.  He  was 
then  so  far  recovered  that  hypnotic  treatment  was  stopped. 
The  patient  went  to  England,  May  12,  1916,  well. 


762  TREATMENT  AND   RESULTS 


Convulsions,   *'  Jacksonian,"  and  dysbasia:  Cure 
by  hypnosis. 


Case  547.     (ToMBLESON,  September,  1917.) 

A  private,  18,  was  admitted  to  hospital,  March  22,  1916, 
with  the  diagnosis  Jacksonian  epilepsy,  with  marked  func- 
tional gait.  He  had  just  had  several  fits  —  two  March  20, 
two  March  21,  and  several  earlier.  He  was  tremulous  and 
could  not  stand.     ]\Iuch  pain.     Knee-jerks  brisk. 

There  was  a  history  of  a  fall  into  a  harbor  at  seven,  fol- 
lowed by  bleeding  from  nose  and  ears  and  unconsciousness 
for  a  week.  Convulsions,  involving  the  face,  arm  and  leg, 
and  attended  by  unconsciousness,  kept  recurring  until  twelve. 
Five  months  before  admission  there  had  been  cerebrospinal 
meningitis.     In  February  at  Salonica  he  had  had  pneumonia. 

]\Iarch  23-24  the  soldier  was  hypnotized  to  the  third  stage, 
but  he  had  two  fits.  A  "  funny  feeling  in  the  right  big  toe  " 
was  brought  out  and  suggested  away.  March  26-27  the 
patient  was  able  to  walk  with  a  typical  functional  disorder. 
Under  somnambulism  the  suggestions  were  repeated,  but  on 
the  evening  of  March  27  two  more  convulsions  appeared. 
In  somnambulism  he  explained  that  he  "  had  got  round  " 
the  inhibition  of  the  aura. 

The  night  of  April  2  occurred  two  convulsions.  April  5, 
the  man  was  placed  in  the  somnambulistic  stage  to  last  three 
days.  During  the  night  of  April  6  he  was  observed  to  be 
restless  for  an  hour,  with  some  twitching  of  the  right  face,  yet 
no  fit  followed.  The  morning  of  /Vpril  8  the  patient  woke 
feeling  well.  He  was  again  placed  in  somnambulism  to  last 
two  days.  Two  hours  later,  however,  a  fit  started.  It  was 
stopped  at  once  by  suggestion,  but  the  patient  woke.  He  was 
left  awake  the  rest  of  the  day.  April  9,  somnambulism: 
suggestions  repeated;  sleep  to  last  for  two  days.  That 
evening  there  was  a  slight  beginning  of  a  fit,  which  was 
stopped  at  once  by  suggestion,  the  patient  waking  April  11 
in  another  beginning  of  a  fit,  stopped  by  suggestion. 

Thereafter  no  more  fits  recurred  at  all.     May  12,  1916,  well. 


TREATMENT  AND  RESULTS  763 


Agoraphobia:   Cure  by  hypnosis. 


Case  548.     (Hurst,  1917.) 

A  captain  was  (with  one  lieutenant)  the  sole  survivor 
among  his  battalion  officers  at  Ypres.  The  captain  received 
the  D.  S.  O.  for  his  gallant  conduct  in  saving  the  remnant  of 
his  battalion.  He  now  felt  he  could  never  face  responsi- 
bility again  and  that  he  would  disgrace  himself  if  he  ever  got 
into  danger.  He  developed  a  terrible  dread  of  open  places 
and  became  more  and  more  depressed.  When  he  heard  that 
there  was  going  to  be  an  attack  at  Neuve  Chapelle,  he  broke 
down  but  managed  to  get  through  the  first  day  of  the  battle. 
He  was  worse  off  than  ever  in  the  evening,  felt  that  he  could 
not  face  another  day's  fighting,  was  invalided  home,  and 
arrived  in  a  condition  of  exhaustion  and  feeling  of  disgrace. 
He  had  bad  dreams  at  night.  Rest  was  insufficient  to  restore 
confidence.  Hypnosis  was  followed  by  rapid  improvement, 
and  the  man  was  soon  able  to  get  back  to  duty. 

Re  agoraphobia,  see  Section  A,  XI,  Psychopathoses,  and 
also  Steiner's  case  (182)  of  claustrophobia,  in  which  shells 
were  preferred  to  safety  in  a  tunnel. 


764  TREATMENT  AND  RESULTS 


Stress  on  Eastern  front;  cardiac  seizures;  cellu- 
litis :  In  convalescence,  manual  tremors.  Treat- 
ment eventually  by  forcing  and  isolation. 


Case  549.     (BiNSWANGER,  July,  1915.) 

A  subaltern  officer,  24,  in  civil  life  a  student  of  mathematics, 
had  serious  hereditary  taint  on  both  sides  (father,  alcoholic; 
maternal  grandfather,  victim  of  "  severe  nervous  disease  "). 
As  a  boy  he  developed  normally,  and  was  a  good  student. 
He  served  as  volunteer  in  191 1  to  1912,  but  in  drill  in  1913  he 
had  had  to  be  released  from  service  on  account  of  nervous 
heart  and  difficulty  with  respiration. 

However,  he  was  called  to  the  colors  at  the  outbreak  of 
the  war,  and  was  subjected  to  tremendous  strain  in  the 
eastern  campaign;  and  he  was  put  in  the  pack  train  at  the 
end  of  November  for  cardiac  seizures.  He  had  a  cellulitis 
with  furunculosis  following,  and  at  the  beginning  of  December 
there  was  suppuration  of  the  whole  right  tibia.  He  was 
treated  in  hospital  and  slowly  recovered. 

At  the  beginning  of  March,  191 5,  without  obvious  exter- 
nal cause,  while  sitting  in  a  cafe,  the  convalescent  officer  felt 
a  cramp  in  his  right  hand,  and  strong  movements  of  the  hand 
to  right  and  left  followed.  He  was  treated  with  bromides, 
but  unsuccessfully.  The  tremors  became  more  marked  and 
then  again  from  time  to  time  grew  weaker.  Electric  treat- 
ment increased  the  shaking  to  a  maximal  degree.  April  27, 
the  patient  was  brought  to  the  nerve  hospital  at  Jena. 

The  patient  was  a  fat  and  muscular  man,  of  average  size, 
with  very  small  ears  and  poorly-developed,  adherent  lob- 
ules, and  syndactylism  of  the  second  and  third  toes  of  both 
feet;  reflexes  increased;  marked  dermatographia ;  a  static 
fine  tremor  with  rapid  oscillations.  The  tremor  became  a 
positive  tonus  if  the  arm  and  hand  were  stretched  out  hori- 
zontally.    Face  and  chest  reddened  easily. 

Whenever  any  other  voluntary  movement  was  carried  out 
(even  slight  finger  movements  of  the  left  hand  or  of  the  right 
or  left  foot  while  lying  in  bed)  this  right-sided  convulsive 


;  TREATMENT  AND   RESULTS  765 

tremor  immediately  disappeared.  The  movements  could  also 
be  made  to  disappear  by  slight  turning  movements  of  the 
head  or  of  the  tongue.  Moreover,  when  the  mind  was 
diverted,  as  in  reading,  the  tremors  ceased.  When  the 
patient  thought  intensely  of  some  mathematical  problem,  he 
could  bring  his  shaking  to  a  stop.  The  left  grip  was  stronger 
than  the  right.  In  the  Romberg  position  there  was  a  marked 
swaying  to  the  left  and  backwards. 

Subjectively,  the  patient  complained  of  nothing  but  a 
circumscribed  headache  in  the  left  parietal  region  and  of 
sleep  interrupted  by  frightful  dreams.  At  first  the  condition 
remained  unchanged.  There  was  much  insomnia,  and  the 
slightest  noise  caused  fright.  Headaches  in  the  daytime  also 
were  produced  by  any  noise,  and  these  headaches  were 
localized  in  the  left  parietal  region.  The  tremors  of  the 
right  hand  persisted  except  as  he  caused  them  to  stop  as 
above  mentioned.  He  could  write  well  with  his  left  hand. 
He  would  drum  with  his  left  hand  on  the  table  until  the  tremor 
of  his  right  hand  disappeared.  He  could  play  on  the  piano, 
playing  first  with  the  left  hand  until  the  right  had  become 
quiet.  He  was  a  very  irritable  man,  passing  into  anger  and 
extreme  profanity  at  the  slightest  occasion,  and  it  was  very 
difficult  to  bring  him  to  any  kind  of  orderly  activity  or  per- 
sistence in  therapeutic  measures.  These  consisted  of  baths, 
massage,  and  gymnastics,  but  they  proved  quite  unavailing. 

As  the  fellow  got  more  and  more  intolerable,  and  as  upon 
May  27  at  about  9  o'clock  in  the  evening,  he  disturbed  the 
quiet  of  the  entire  hospital  by  a  severe  paroxysm  of  scolding, 
he  was  placed  in  a  single  room  in  the  psychiatric  department. 
He  was  placed  in  bed,  cut  ofif  from  all  communication  with 
others,  and  forced  to  carry  out  his  exercises. 

For  two  days  he  was  surly,  crabbed  and  obstinate,  but 
then  changed  his  demeanor  completely;  he  became  friendly 
and  obedient.     The  tremor  completely  disappeared. 

Five  days  later  he  was  able  to  carry  out  all  active  gymnas- 
tic exercises  with  great  energy  and  without  the  slightest  dis- 
turbance in  the  right  arm.  At  date  of  report  he  was  busy  in 
the  garden. 


766  TREATMENT  AND  RESULTS 


Five  weeks'  field  service:   Loss  of  speech.     Cure 
by  verbal  and  electric  suggestion  in  three  weeks. 


Case  550.     (ScHOLZ,  December,  1915.) 

A  grenadier,  21,  of  healthy  stock,  physique,  and  habits, 
lost  his  speech,  April  15,  191 6,  five  weeks  after  going  into  the 
field.  May  5,  examination  showed  him  a  well-nourished 
healthy  man  (lively  reflexes  and  slight  dermatographia),  able 
to  communicate  only  by  signs  and  writing.  The  laryngo- 
scope showed  almost  complete  immobility  of  the  two  vocal 
cords,  which  lay  in  the  cadaveric  position,  as  in  paralysis 
of  the  recurrent  nerves.  In  endeavoring  to  pronounce  the 
vowels  a  and  ee  the  cords  trembled  but  failed  to  move  toward 
each  other.  The  patient's  effort  to  speak  was  such  that  his 
head  soon  got  deep  red  and  sweat  streamed  from  the  forehead. 

Speech  exercises  were  started  by  passing  the  electric 
current  through  the  larynx  during  the  processes  of  laryngos- 
copy. The  patient  was  meantime  assured  that  his  larynx 
was  healthy  and  that  he  would  soon  learn  to  speak  again. 
At  the  first  sitting,  the  patient  felt  himself  able  to  cough 
aloud. 

After  a  few  days,  the  patient  was  able  to  speak  the  separate 
vowels  tolerably  well,  and  was  then  made  to  go  on  with  such 
words  as  Anna,  Otto,  Hurrah.  The  vocal  cords  began  to 
move  better.  Fatigue  was  a  feature  of  the  first  treatments, 
of  such  a  degree  that  words  that  could  be  pronounced  during 
the  first  part  of  the  sitting  were  lost  toward  the  close. 

The  grenadier  assiduously  set  himself  to  say  over  and  over 
again  the  words  that  he  had  learned,  and  would  come  to  the 
sister  radiant  with  joy  at  his  success.  In  ten  days  he  was 
able  to  speak  again  perfectly,  though  giving  the  impression 
of  a  slight  stuttering.  After  three  weeks  hospital  stay  he  was 
discharged  cured  and  fit  for  service. 


TREATMENT  AND   RESULTS  767 


Struck  by  a  rifle  butt  on  right  side  of  head;  old 
wound  of  right  thigh:  Hysterical  right  hemiplegia 
and  deafmutism.  Treatment  by  faradization :  Re- 
turn of  speech  and  improvement  of  hearing.  Full 
recovery  by  suggestion.  Hysterical  CONVUL- 
SIONS developed  BY  HETEROSUGGESTION 
from  convulsive  neighbor. 


Case  551.     (Arinstein,  1915.) 

A  Russian  corporal,  21,  was  knocked  unconscious,  Sep- 
tember 13,  1915,  by  a  butt  of  a  rifle  which  struck  the  right 
side  of  his  head.  He  came  to  in  a  short  time.  He  was 
examined  in  hospital,  early  in  October,  and  besides  a  small 
skin  wound  of  the  head,  there  was  evidence  of  a  wound  on 
the  anterior  aspect  of  the  thigh.  There  was  paralysis  of  both 
right  arm  and  right  leg,  and  anesthesia  of  the  entire  right  side 
of  the  body,  face  and  even  of  the  tongue.  There  were  also 
pains  over  the  whole  right  side  of  the  body.  The  abdominal 
reflexes  were  present  on  both  sides;  the  tendon  reflexes  were 
in  excess  on  the  hemiplegic  side;  there  were  no  pathological 
reflexes  of  any  sort.  The  patient's  hearing  was  diminished, 
and  he  could  not  speak  at  all  although  he  could  understand 
the  speech  of  others  perfectly. 

Speech  returned  after  a  single  seance  of  suggestion  with 
faradism  to  the  throat.  Hearing  began  to  improve.  The 
patient's  suggestibility  was  a  favorable  factor  In  his  cure, 
but  there  were  some  unfavorable  features.  One  day,  he  saw 
a  neighbor  go  into  convulsions  and  proceeded  to  develop 
convulsions  himself.  These  hysterical  convulsions  continued. 
According  to  Arinstein,  such  undesirable  complications  ap- 
pear under  conditions  of  extreme  crowding  of  hospital  pa- 
tients suffering  from  shell-shock.  Progressive  seances  of 
psychotherapy  caused  the  disappearance  of  all  the  signs  of 
paralysis,  and  at  the  time  of  the  report,  there  was  no  dis- 
ability, except  that  the  full  use  of  the  hand  had  not  yet  been 
regained- 


768  TREATMENT  AND   RESULTS 


Shell-shock  and  burial;  labyrinthine  disease  on 
one  side:  DEAFMUTISM.  Cures,  relapses  and 
eventual  cure  by  general  anesthesia,  more  than  four 
months  after  shock. 


Case  552.     (Dawson,  February,  1916.) 

A  private,  30,  had  been  12  years  in  the  service.  July  8, 
191 5,  he  was  partially  buried  by  a  shell  which  killed  two 
companions. 

On  admission  to  hospital  he  spoke  a  few  sentences  but 
was  deaf,  and  next  morning  could  neither  speak  nor  read, 
nor  did  he  take  food  for  36  hours  thereafter. 

Admitted  to  the  King  George  Hospital,  July  18,  he  was 
found  stuporous,  but  started  violently  if  touched,  made 
signs  indicating  his  wants,  took  no  interest  in  surroundings, 
and  resisted  efforts  to  arouse  him.  He  was  without  signs  of 
organic  disease.  It  seems  that  he  had  been  a  ner\"ous  child, 
with  nightmares  and  fits. 

July  24,  he  was  given  gas  for  dental  extraction,  partly  in 
the  hope  that  he  would  recover  speech;  but  though  he 
struggled  violently,  he  made  no  sound.  He  had  by  this 
time  become  rather  intelligent  in  a  childlike  manner,  being 
pleased  to  see  his  small  boy,  but  taking  no  notice  of  his  wife. 
It  transpired  afterward  that  he  did  not  recognize  her. 

Phonatlon  in  whisper  now  began.  There  was  then  a  re- 
lapse, and  for  a  week  or  more  no  food  was  taken.  Such 
relapses  with  irritation  and  hypobulia  and  an  obstinate 
constipation  recurred;  but  improvement  came  on  slowly. 
He  became  able  to  read  short  printed  words,  and  later 
handwriting. 

For  another  month  there  was  no  improvement  and  he 
lost  heart  and  the  will  to  get  well,  brightening  up  only  when 
offered  a  motor  drive  or  something  else  pleasant.  He  was 
transferred  to  an  auxiliary  hospital,  against  his  will,  Sep- 
tember 18. 

November  i ,  he  was  brought  back  to  the  King  George  Hos- 
pital, excited,  shouting,  struggling  and  evidently  drunk.     On 


TREATMENT  AND  RESULTS  769 

a  day's  leave  from  the  convalescent  hospital  he  had  come  up 
to  London,  and  in  alcoholic  elation  began  to  laugh  and  talk. 
Morphia  did  not  reduce  his  violence.  He  insisted  on  seeing 
the  physician,  to  tell  him  the  good  news.  Hearing  was  still 
diminished,  though  if  attention  were  diverted,  direct  answers 
were  given  to  some  questions.     Sleep  followed. 

The  next  day  he  spoke  perfectly  but  could  hear  nothing. 
There  was  no  further  progress  for  three  weeks,  though  he 
occasionally  caught  sounds.  He  now  became  bright  and 
pleasant  and  had  lost  all  irritability  and  sulkiness.  Galvanic 
and  faradic  current  had  no  effect  on  the  ears. 

November  2"!,  after  elaborate  preparation  to  heighten  the 
suggestive  effect,  the  patient  was  kept  in  bed  and  given  gas 
and  ether  up  to  the  abolition  of  the  corneal  reflex.  As  he  was 
coming  round,  the  doctor  shouted  that  he  could  now  hear  well. 
He  was  overcome  with  joy  and  had  hysterical  convulsions. 
He  could  hear,  but  with  the  right  ear  only.  In  point  of  fact, 
the  left  ear  on  examination  showed  signs  of  labyrinthine  deaf- 
ness.    He  was  placed  on  home  service. 

Ke  etherization  for  functional  deafness  and  mutism,  Ninian 
Bruce  maintains  that  ether  is  more  satisfactory  than  chloro- 
form. The  loss  of  consciousness  in  cases  of  deafness  and 
mutism  ought  to  be  a  relatively  slight  one,  and  the  patient 
should  be  suddenly  roused  to  the  realization  that  he  is  speak- 
ing. Recovery  from  chloroform  anesthesia  is,  according  to 
Ninian  Bruce,  too  slow  to  allow  the  patient  to  catch  the 
point  that  he  is  now  speaking  and  hearing  when  he  was 
formerly  dumb  or  deaf.  A  failure  with  the  method  is  a  bad 
thing  for  the  patient,  as  he  loses  confidence  in  the  method, 
whereupon  some  other  method  must  be  resorted  to. 

Re  etherization  for  deaf  mutism,  see  technic  of  Ninian 
Bruce  under  Case  553.  Penhallow  has  a  case  in  which 
during  primary  etherization  the  patient  reviewed  in  a  loud 
voice  the  whole  story  of  his  speech  loss.  He  was  found  to 
have  recovered  speech  and  hearing  after  coming  out  of  ether. 

Re  anesthesia  by  gas,  Abrahams  has  used  nitrous  oxide  for 
cure  of  hysterical  paraplegia.  Proctor  also  reports  the  use 
of  light  ether  anesthesia  for  bringing  out  the  voice  of  func- 
tional mutes. 


770  TREATMENT   AND    RESULTS 


Shell-shock  functional  deafness  (five  months). 
Yes-No  test.  Cure  by  suggestion  on  emerging 
from  ether  anesthesia. 


Case  553.     (Bruce,  May,  1916.) 

A  soldier  was  admitted  to  the  Royal  Victoria  Hospital, 
Edinburgh,  completely  deaf  in  the  left  ear.  He  had  been 
under  shell  fire  a  number  of  times  in  France  and  was  eventu- 
ally thrown  down  and  made  unconscious  by  a  shell  explo- 
sion on  his  left.  He  did  not  remember  the  noise  of  the 
explosion  or  anything  until  he  found  himself  in  hospital. 
After  the  explosion  he  had  begun  to  stutter,  and  the  stuttering 
had  grown  worse.  Examination  of  the  ear  indicated  that 
the  deafness  was  functional.  He  was  given  ether  and  when 
just  under  was  asked  if  he  could  hear  anything  spoken  in  his 
right  ear.  He  said,  "  Yes."  With  the  right  ear  closed  he 
was  asked  if  he  could  hear  when  his  left  ear  was  spoken  into. 
He  said,  "  No."  This  test  was  repeated  several  times. 
After  covering  his  right  ear,  he  gave  his  name,  regiment, 
etc.,  in  reply  to  questions  whispered  into  his  left  (previously 
deaf)  ear.  The  incongruity  was  pointed  out.  He  was  now 
suddenly  wakened.  He  laughed  hysterically  with  joy  over 
his  recovery. 

But  the  next  morning  he  was  again  stone  deaf  in  the  left 
ear.  Blistering  and  electricity  failed  to  produce  benefit.  He 
was,  however,  puzzled  about  himself. 

After  a  fortnight  he  was  again  given  ether  and  a  little 
chloroform  was  added.  The  yes-no  test  was  again  positive. 
He  was  allow^ed  to  recover  gradually  from  the  chloroform,  but 
he  had  now  lost  recollection  of  what  had  happened.  The 
left  ear  remained  deaf.  Ether  was  again  given.  He  was 
asked  to  close  his  right  ear  with  his  finger.  While  answering 
questions  addressed  to  his  left  ear,  he  was  suddenly  awakened 
and  immediately  said  that  his  hearing  had  come  back. 
This  return  proved  permanent.  He  returned  to  his  depot. 
In  the  conversations  under  ether  there  was  no  stuttering. 
He  had  been  totally  deaf  in  the  left  ear  for  five  months. 


TREATMENT   AND    RESULTS  77 1 


Blow  in  neck  by  rifle  butt:  aphasia,  right  hemi- 
plegia and  hemianesthesia,  and  especially  (here 
MEDICAL  suggestion)  trismus:  Recovery  by  an- 
esthetic and  suggestion. 


Case  554.     (Arinstein,  September,  19 15.) 

A  Russian  soldier  was  struck  in  the  head  and  neck  by  a 
rifle  butt,  and  developed  paralysis  of  right  arm  and  leg  with 
loss  of  speech.  After  the  excitement  experienced  by  the 
patient  when  exhibited  to  the  students  by  the  late  Prof.  M.N. 
Szukowsky  in  the  neurological  clinic  of  the  Military  Medical 
Academy,  trismus  developed. 

The  patient  spent  a  year  in  various  hospitals,  the  most 
diverse  methods  of  treatment  by  drug  therapy,  electricity, 
and  suggestion  yielding  no  results.  The  patient  had  to  be 
fed  chiefly  by  nose  and  rectum,  though  small  quantities  of 
fluids  were  fed  through  the  mouth  through  an  opening  formed 
by  the  falling  out  of  one  tooth  in  the  upper  jaw.  The  patient 
became  greatly  emaciated  and  weak  and  was,  October  29, 
1 91 5,  brought  Into  the  nervous  wards  of  the  hospital. 

He  showed  flaccid  paralysis  of  left  arm  and  leg,  together 
with  anesthesia,  analgesia  and  thermanesthesia  over  the  whole 
left  side  of  the  head,  extreme  general  atrophy  of  muscles, 
somewhat  more  marked  on  the  palsied  side.  The  tempera- 
ture of  the  paralyzed  half  of  the  body  was  not  lowered.  No 
knee  or  Achilles  reflex  obtained  upon  either  the  affected  or 
the  healthy  side  (general  exhaustion?).  Abdominal  and 
testicular  reflexes  lively.  The  pupils  responded  well  to 
light.  Corneal  reflexes  lively.  The  neck  was  held  awry  to 
the  left,  and  the  head  was  inclined  somewhat  downwards  and 
leftwards;  hearing  on  left  side  Impaired.  The  jaws  could 
not  be  opened  even  with  the  greatest  effort.  Wassermann 
reaction  negative. 

Patient  thought  himself  incurable.  Purves  Stewart's  case, 
in  which  chloroform  and  oxide  of  nitrogen  were  used,  was  the 
basis  of  Arlnstein's  treatment.  It  was  suggested  to  the 
patient  that  he  submit  to  narcosis  with  the  proviso  that  he 


772  TREATMENT   AND   RESULTS 

would  not  be  operated  upon.  His  consent  was  secured; 
with  the  cooperation  of  others,  the  chloroform  was  adminis- 
tered November  6.  The  stage  of  excitability  was  not  well 
marked.  8  gr.  of  chloroform  was  used  altogether,  by  the 
drop  system.  Nevertheless,  even  with  the  weak  initial 
excitability,  the  patient  became  capable  of  some  movements 
with  paralyzed  hand  and  foot.  On  opening  mouth,  the 
patient  yawned  yet  uttered  no  sound.  Between  the  jaws 
was  put  a  rubber  insertion  and  upon  awakening  the  patient 
was  let  see  with  his  own  eyes  that  his  jaws  were  open  and  that 
therefore  food  might  be  introduced  through  the  mouth. 
Upon  repetition  of  the  narcosis,  5  gr.  of  chloroform  was  used 
altogether,  and  the  stage  of  excitability  was  this  time  better 
marked.  To  strengthen  movements  in  the  paralyzed  ex- 
tremities, the  device  of  pricking  the  patient  with  a  pin  on 
the  unaffected  half  of  the  body,  with  the  unaffected  hand  and 
leg  held  horizontal  by  assistants,  was  adopted.  The  patient 
then  made  reflex  defensive  movements  in  the  paralyzed 
extremities,  especially  the  hand.  At  this  point  the  narcosis 
was  suspended,  and  the  irritation  with  the  pin  was  con- 
tinued until  consciousness  returned.  At  this  moment,  the 
patient's  attention  was  called  to  the  disappearance  of  the 
paralysis  and  his  restored  ability  to  move  the  paralyzed  ex- 
tremities. 

From  that  time  on,  the  patient's  condition  underwent  a 
sharp  transition.  Artificial  feeding  became  unnecessary. 
The  patient  ate  by  mouth;  the  mouth  was  opened  by  the 
leverage  of  a  small  stick  held  by  the  patient  between  his  teeth. 
Speech  returned  gradually.  In  reading  aloud  the  patient 
aided  the  movements  of  his  lips  with  his  hands.  At  the 
time  of  report  the  patient  spoke  well,  ate  normally,  had  gained 
in  weight,  and  with  some  effort  could  sit  down  and  even  stand 
and  walk.  All  this  was  attained  in  a  relatively  short  time 
after  a  whole  year  of  paralysis. 

The  author  felt  that  the  success  attained  in  this  case  gave 
him  the  right  to  use  the  same  method  where  the  cause  was 
not  a  contusion. 


TREATMENT  AND  RESULTS  773 


Ten  months'  field  service;  severe  FEBRILE  DIS- 
EASE :  Afterward  hysterical  TRIPLEGIA,  MUTISM, 
**  JUMPING- JACK  "   reactions  to   stimulation  of 
feet.     Cure     by    anesthesia,    verbal    suggestion, 
faradism  to  palate. 


Case  555.     (Arinstein,  September,  1915.) 

A  Russian  private,  30,  brought  to  a  field  reserve  hospital, 
June  20,  1915,  was  in  a  grave  condition  diagnosed  typhoid. 
By  the  end  of  June  the  general  condition  had  improved  and 
the  temperature  had  fallen. 

July  9,  worse;  happening  to  be  in  the  company  of  a  sanitary 
in  a  privy,  he  was  observed  suddenly  to  fall  unconscious, 
with  both  feet  and  left  arm  paralyzed.  Soon  afterward  he 
lost  the  power  of  speech.  From  September  30  to  October 
19,  he  lay  in  field  hospital;  but  was  then  transferred  to  the 
nerve  hospital  with  diagnosis:  convulsive  paralysis  and 
aphasia.  At  entrance,  complete  paralysis  of  both  legs  and 
left  hand;  loss  of  speech  and  aphonia  (speech  understood). 
Upon  touching  a  foot,  strong  convulsions  developed  with  legs 
rapidly  drawn  apart  and  drawn  together  much  in  the  man- 
ner of  dancing  toys.  The  mouth  was  twisted  to  the  left. 
Though  he  silently  opened  his  mouth  and  made  rapid  move- 
ments with  the  lower  jaw,  he  could  not  utter  a  single  sound, 
either  vowel  or  consonant.  Left  hypalgesla.  Hypesthesia 
of  skin  of  hand  and  mucosa  of  tongue.  Knee-jerks  absent 
because  of  the  strain  of  the  muscles  of  the  legs.  Wassermann 
negative. 

The  history  showed  that  the  speech  of  the  patient  had  been 
incorrect  and  indistinct  from  childhood.  Moreover,  In  1908, 
in  chopping  wood  In  the  forest  he  had  fallen  under  a  sleigh 
and  hurt  his  left  hand,  which  had  not  since  fully  recovered. 
He  had  volunteered  for  the  war. 

The  psychogenic  character  of  the  disease  seemed  clear. 
Suggestion  was  followed  by  ether  narcosis,  during  which,  on 
pricks  of  the  healthy  side  with  a  pin,  the  patient  made 
defensive  movements  with   the  paralyzed   hands,   and   also 


774  TREATMENT  AND  RESULTS 

moved  both  legs.  Speech  was  not  regained  either  during 
or  immediately  after  the  narcosis,  although  the  patient  gave 
forth  indefinite  sounds.  Speech  was  restored  on  the  same 
day,  September  7,  with  verbal  suggestion  and  faradic  brush 
applied  to  palate.  The  patient  at  once  began  to  speak 
clearly  and  distinctly,  read  his  prayer  book,  and  described 
distinctly  and  in  detail  how  he  went  to  war.  From  that 
moment  the  convulsive  movements  in  the  feet  disappeared, 
the  region  of  anesthesia  on  the  left  side  narrowed,  speech 
was  permanently  reestablished,  and  the  patient  began  to 
move  with  his  feet  and  finally  began  to  walk  after  six  months 
of  paralysis.  Before  that  time  no  medical  treatment  had  had 
the  slightest  effect.  The  effort  to  stop  mechanically  the 
jerks  even  temporarily  by  means  of  plaster  casts  had  been 
unsuccessful.  In  sleep  the  twitches  ceased,  but  upon  re- 
awakening, even  before  full  consciousness  returned,  the 
jerkings  would  resume.  It  is  curious  to  note  that  upon 
falling  asleep  under  the  anesthetic  the  patient  w^ould  issue 
always  one  and  same  kind  of  yells  —  ^^  Help,  there  goes  the 
Germayi!     They  are  shooting!     Russians,  do  not  yield! 

Re  chloroform  anesthesia,  Milligan  remarks  that  the  treat- 
ment should  be  carried  out  in  a  quiet,  single  room,  wdth  the 
chloroform  slowly  administered  and  the  suggestions  made 
by  the  anesthetist  during  the  optimal  phase  for  suggestion, 
—  just  before  the  stage  of  involuntary  struggling. 


TREATMENT  AND  RESULTS  775 


Shell-shock ;  unconsciousness :  Mutism  and  musi- 
cal alexia.     Cure  by  anesthesia. 


Case  556.     (Proctor,  October,  1915.) 

A  private,  23,  was  admitted  to  the  Duchess  of  Connaught's 
Hospital  at  Taplow  from  GallipoH,  September  10,  19 15. 
A  shell  had  exploded  behind  this  man.  He  had  been  picked 
up,  unconscious,  and  remained  so  about  a  day.  He  re- 
covered without  the  power  of  speech.  Cerebration  was  slow 
at  first  but  improved  steadily. 

The  man  had  been  a  professional  musician.  Curiously 
enough,  though  his  ability  to  read  ordinary  print  was  as  good 
as  ever,  his  reading  of  music  was  lost  with  the  speech. 

September  20,  he  was  etherized,  but  being  of  a  phlegmatic 
type,  he  was  not  readily  excited  and  took  the  anesthesia  very 
quietly.  After  perseverance,  however,  he  was  induced  to 
talk.  The  ability  to  read  music  returned  with  the  voice. 
He  was  discharged,  October  4,  1915. 

Re  the  use  of  anesthetics  for  curing  deafmutism,  Colin 
Russel  rather  disapproves  of  this  method  on  the  ground 
that  no  attempt  is  made  to  get  at  the  genuine  pathogenesis 
of  the  case  and  that  accordingly  there  may  be  a  tendency  to 
recurrence. 

Re  the  peculiar  musical  alexia,  see  discussion  under  Cases 
353  and  450  of  confusion  and  amnesia.  The  most  highly 
selective  amnesias  have  been  found  in  confusional  cases. 
However,  Case  556  had  been  a  professional  musician  and 
the  effect  may  have  been  a  highly  speciahzed  suggestion. 
See  also  Case  369  of  Felling  for  differentiated  musical  dis- 
order. Mott  has  used  the  retained  knowledge  of  tones  as 
an  avenue  of  approach  in  certain  mute  cases. 


776  TREATMENT  AND  RESULTS 


Shell-shock ;  burial  (24  hours  ?) ;  unconsciousness, 
13  days :  Deaf  mutism.  Chloroform  narcosis  cured 
the  deafness  (!),  not  the  mutism. 


Case  557.     (Gradenigo,  March,  191 7.) 

An  Italian  infantryman  was  buried  under  Mt.  Zebio  after 
shell  explosion.  After  24  hours  he  was  found  and  dug  out. 
He  remained  unconscious  for  13  days  and  came  out  abso- 
lutely deaf  and  mute. 

At  hospital  he  was  markedly  depressed  and  cried  very 
readily  on  being  spoken  to.  The  tympanic  membrane  had 
lost  its  sensitiveness  to  pain.  As  for  the  speech  mechanism, 
the  larynx  proved  negative.  All  the  movements  of  the  soft 
palate,  tongue  and  vocal  cords  could  be  normally  performed. 
The  tongue  was  anesthetic  to  touch,  but  the  taste  function 
was  perfectly  preserved.  The  cheeks  and  various  parts  of 
the  face  were  also  anesthetic  to  touch,  and  the  lobules  of  the 
ears  could  even  be  pierced  with  large  pins  without  reaction 
by  the  patient. 

He  tried  to  pronounce  labials,  opening  and  closing  the  lips 
rapidly;  but  the  expiratory  movement  was_too  weak,  and 
not  a  single  sound  was  made. 

At  the  patient's  request,  he  was  chloroformed.  During  a 
very  violent  excited  phase,  he  did  emit  groaning  sounds. 
The  narcosis,  however,  did  not  put  an  entire  stop  to  the 
mutism,  since  only  a  few  inarticulate  sounds  could  be  emit- 
ted, and  those  only  after  great  efforts.  Curiously  enough, 
however,  the  chloroform  narcosis  had  caused  the  deafness  to 
disappear  entirely.  Another  narcosis  upon  the  patient's 
insistent  request  was  given  but  remained  without  results, 
and  at  the  time  of  report,  the  patient  though  cheerful  and 
intelligent-looking,  was  still  mute. 


TREATMENT  AND  RESULTS  777 


Treatment  of  two  cases. 


Cases  558  and  559.     (Smyly,  April,  1917.) 

A  soldier  was  out  with  a  bombing  party  when  a  shell  burst. 
He  came  to  in  a  casualty  clearing  station,  and  was  sent  on  to 
Salonica,  deaf,  dumb  and  jumpy.  Two  months  later,  an 
attempt  at  hypnosis  failed;   faradism  of  vocal  cords  failed. 

The  patient  dreamed  one  night  that  if  he  vomited  he  could 
speak.  Ipecac  produced  vomiting  without  speech.  The 
patient,  however,  wanted  a  second  dose,  and  while  waiting 
for  it,  uttered  an  exclamation,  which  he  did  not  himself  hear, 
however.  In  the  meantime,  Dr.  Smyly  had  been  trying  to 
hypnotize  a  second  soldier,  dumb  but  not  deaf.  This  man's 
dug-out  had  been  blown  in  on  him  seven  months  before, 
whereupon  the  patient  became  very  shaky,  but  did  not  be- 
come sick  for  a  week.  He  was  then  sent  to  hospital,  and  his 
voice  gradually  disappeared.  He  suffered  from  violent 
headache  and  spasmodic  movements  of  the  arms  and  legs. 
Suggestion  seemed  powerless,  and  ether  was  unexpectedly 
given  to  the  patient.  While  going  under  the  ether,  he  said, 
"  Oh  dear,  oh  dear  "  several  times  indistinctly.  It  seems 
that  another  physician  had  already  tried  to  cure  the  patient 
of  dumbness  by  removing  teeth  without  an  anesthetic. 

While  this  therapy  was  proceeding  with  the  dumb  man, 
the  deaf-and-dumb  man  disappeared.  It  seems  that  the 
smell  of  the  gas  had  caused  him  to  take  refuge  on  an  out- 
house-roof. The  next  day  he  had  recovered  voice  and 
hearing  completely,  partly  from  shock  and  partly  through 
suggestion. 

The  etherized  patient  did  not  recover  voice  but  lost  the 
spasmodic  movements  and  his  insomnia.  A  week  later 
ether  was  again  administered,  and  the  patient  was  strapped 
down;  as  he  was  coming  to,  faradism  was  applied  to  the  head 
and  face.  The  patient  then  quickly  recovered  his  voice  and 
still  retains  it. 


778  TREATMENT  AND  RESULTS 


Shell  wound:  Hysterical  dysbasia  from  contrac- 
ture. Many  methods  of  treatment  fail.  Success 
with  "  a  new  measure,"  e.g.  stovaine. 


Case  560.     (Claude,  March,  191 7.) 

A  sergeant  was  struck  in  the  suprapubic  region,  December 
15,  1915,  by  a  shell  fragment  and  got  a  large  hematoma  in 
the  perineal  region  (shell  fragment  visible  on  X-ray).  The 
man  was  treated  a  year  in  a  center  for  physiotherapy  and  was 
then  treated  in  a  neurological  center,  where  a  faulty  position 
of  the  right  thigh  maintained  in  extensor  rotation  and  ab- 
duction was  found.  The  patient  walked  on  crutches,  legs 
wide  apart,  balancing  with  body. 

Upon  transfer  to  Bourges,  an  intraspinal  injection  of  sto- 
vaine (after  withdrawal  of  2-3  cc.  fluid,  i  cc.  stovaine, 
0.07  to  the  cc,  mixed  with  cerebrospinal  fluid)  was  made. 
This  reduced  the  contracture  and  permitted  the  patient  to 
place  his  legs  parallel.  They  were  then  bandaged  In  the 
parallel  position.  The  bandages  were  removed  two  days 
later  and  the  limbs  did  not  reassume  their  faulty  position. 
The  man  was  shortly  able  to  walk  with  a  cane ;  progress  was 
rapid.  This  man  was  very  desirous  of  cure  and  refused 
to  be  invalided,  believing  he  was  to  be  cured,  and  had  re- 
ceived medal  and  war  cross.  Simple  motor  reeducation  in 
competent  hands  had  been  without  effect.  A  new  kind  of 
measure,  such  as  stovaine,  proved  successful. 

Re  "new  measures"  for  hysteria,  see  items  under  Case 
516.  See  also  remarks  upon  cures  by  lumbar  puncture  under 
Case  488. 


TREATMENT   AND    RESULTS  779 


Burial:  Hysterical  dysbasia.    Treatment  by   sto- 
vaine  anesthesia. 


Case  561.     (Claude,  March,  1917.) 

A  chasseur,  buried  June  24,  19 16,  had  a  number  of  general 
symptoms,  apparently  got  well  and  was  given  seven  days' 
leave  at  home.  On  the  way  he  felt  abdominal  pain  which 
he  thought  due  to  the  jolting  of  the  car.  Suddenly  he  felt  his 
legs  trembling  on  extension.  He  left  the  train  and  went  into 
a  hospital  where  a  diagnosis  of  radicular  and  spinal  lesions 
was  made.  Two  months  later  he  was  sent  to  Claude  who 
found  that  he  could  walk  only  with  knees  flexed.  If  he  was 
requested  to  stand  up  and  extend  his  legs  on  the  thigh,  a 
trembling  set  in  suggestive  of  an  epileptoid  trepidation. 
Even  in  the  horizontal  position  the  same  clonic  trepidation 
occurred  which  only  stopped  if  the  patient  flexed  his  legs  on 
the  thighs. 

However,  no  sign  of  organic  lesion  could  be  found.  There 
was  an  analgesia  limited  to  the  ankles.  Psycho- physio- 
therapeutic treatment  was  unavailing.  January  28,  191 7, 
the  stovaine  injection  method  was  tried.  After  anesthesia 
had  set  in,  it  was  found  possible  still  to  produce  the  spastic 
state  by  extending  the  legs;  but  a  half  hour  after  injection 
the  spastic  state  could  no  longer  be  produced.  The  patient 
was  shown  that  the  trepidation  was  abolished.  During  the 
period  of  return  of  sensibility,  the  legs  were  constantly  moved 
and  the  patient  constantly  told  to  make  movements  himself. 
He  was  convinced  of  his  power.  There  was  no  longer  any 
clonus.  The  patient  remained  all  day  in  bed  without  epilep- 
tiform movements.  Next  day  he  complained  merely  of 
weakness  in  the  legs  and  was  got  to  walk  without  having 
convulsive  tremors.  During  the  next  few  days  he  began  to 
walk  with  a  cane,  later  without  support,  and  there  were  no 
more  contractions  except  transiently  in  the  left  leg  if  the 
patient  walked  a  little  too  long.     He  left  the  hospital  cured. 


780  TREATMENT    AND   RESULTS 


Shell-shock  deafmutism :  Psychic  treatment. 


Case  562.     (Bellin  and  Vernet,  January,  1917.) 

A  soldier  in  a  colonial  regiment  was  sent,  August  14,  1916, 
to  an  evacuation  post  with  a  diagnosis  "  deafness  following 
shell-shock,  unfit  for  service."  The  patient  asked  that  he 
be  spoken  to  very  loud  because  he  could  not  hear,  and  he 
himself  spoke  in  whispers.  He  kept  watching  his  interlocu- 
tors' lips  and  moved  his  own  as  if  to  pronounce  the  words. 

A  shell  had  burst  nearby  fourteen  months  before  in  June, 
191 5.  After  being  in  several  hospitals,  he  was  sent  to  an 
oto-rhino-laryngological  service  where  he  had  his  hearing 
reeducated  and  was  taught  lip  reading.  It  was  soon  per- 
ceived that  he  could  hear  without  lip  reading  and  he  was 
assured  that  he  could  be  cured  at  once,  but  naturally  he  was 
not  convinced.  He  produced  a  carefully  filed  paper  stating 
"  atrophic  ozenous  rhinitis,  deafness  from  labyrinthine  shock 
following  shell  explosion,  hearing  diminished  60  per  cent  right, 
30  per  cent  left." 

However,  energetic  psychotherapy  was  started  and  in  the 
absence  of  electricity,  subcutaneous  injections  of  ether  were 
given.  Such  patients  had  always  been  cured,  and  a  drug 
injected  under  the  skin,  not  dangerous  but  extremely  painful 
would  cure  him!  This  treatment  was  carried  out  in  a  dugout 
near  enough  to  the  lines  to  be  daily  "  potted."  The  patient 
was  left  for  a  space  to  reflect,  and  he  finally  accepted  the 
chance  of  cure.  He  was  exhorted  to  stand  courageously  the 
pain  and  to  breathe  deeply  and  to  repeat  a  word  more  and 
more  loudly.  Finally  he  was  made  to  speak  normally  and 
eventually  to  cry  out  loudly.  He  now  felt  much  astonished, 
and  in  his  astonishment  forgot  his  deafness.  He  said  that 
he  had  never  spoken  or  heard  since  the  accident,  that  he  had 
been  a  deafmute  from  the  first  month  of  his  illness,  and  that 
for  the  last  three  months  he  had  been  able  to  speak  only  in 
a  whispered  voice. 

He  should  have  been  watched  a  few  days  to  confirm  the 
cure.     This  was  impossible  in  the  crowded  dugout  and  no 


TREATMENT   AND   RESULTS  78 1 

risk  could  be  run  of  his  escaping.  Kept  over  night  he  was 
found  next  day  unable  to  hear  and  talking  in  the  same 
voice  as  before. 

He  was  now  found  to  be  either  an  exaggerator  or  a  simu- 
lator. He  was  given  a  half  hour  to  exercise  his  voice  in  and 
told  that  he  must  succeed  unless  he  was  a  simulator.  At 
the  end  of  half  an  hour  it  was  found  that  he  had  skipped. 
He  was  sent  back  by  the  division  surgeon  with  orders  to  send 
him  to  the  otological  service  for  inquiry.  The  otological 
service  found  an  atrophic  ozenous  rhinitis,  a  normal  larynx, 
perfect  audition.  He  was  given  a  psychic  X-raying  and  a 
few  electric  sparks  were  also  drawn  from  his  neck.  He  then 
began  to  talk  in  a  loud  voice  and  to  hear  normally.  August 
30,  he  was  sent  out  completely  cured  and  rejoined  his  regi- 
ment. 

Re  treatment  of  deafmutism  by  other  means  than  pseudo 
operations  and  anesthesia,  see  remarks  under  Case  556  con- 
cerning Colin  Russel's  opinion  that  anesthesia  does  not  get 
at  the  true  genesis  of  cases.  Re  the  teaching  of  lip  reading 
to  Shell-shock  deafmutes,  see  discussion  under  Case  580. 


782  TREATMENT   AND    RESULTS 


Brachial  monoplegia.    Cure  by  electrical  suggestion 
(physician  bored-looking,  brief,  and  authoritative). 


Case  563.     (Adrian  and  Yealland,  June,  191 7.) 

Adrian  and  Yealland  had  occasion  to  treat  an  officer  with 
a  persistent  functional  paralysis  of  the  arm,  which  had  suc- 
cessfully withstood  hypnotism,  psychoanalysis,  rest,  massage, 
anesthesia  with  ether,  and  painful  electrical  treatment. 

This  patient  knew  something  of  the  functions  of  the  brain 
and  was  prepared  to  discuss  his  condition  exhaustively.  He 
was  told,  however,  that  he  had  come  to  be  cured  and  that 
the  nature  of  his  cure  would  be  explained  to  him  afterwards. 
Without  further  discussion,  the  motor  areas  of  the  cortex 
were  mapped  out  rapidly.  The  measurements  were  repeated 
aloud  to  impress  and  mystify  the  patient.  He  was  assured 
that  as  soon  as  the  shoulder  area  of  the  cortex  was  stimulated 
faradically,  he  would  be  able  to  raise  his  shoulder,  and  that 
then  the  rest  of  his  arm  would  recover.  An  exceedingly 
mild  faradic  current  was  then  applied  to  the  scalp  for  a  few 
moments  and  he  was  then  ordered  to  move  his  shoulder.  He 
did  so  at  once.  In  a  few  minutes,  all  of  the  paralysis  had 
vanished  and  the  patient  could  raise  30  pounds.  Adrian  and 
Yealland  believe  that  the  success  here  was  largely  due  to  the 
fact  that  the  patient  was  not  allowed  to  discuss  the  case  or 
criticize  the  treatment  beforehand. 

It  is  essential  that  the  patient  should  be  convinced  that 
the  physicians  understand  the  case  and  can  cure  him.  No 
physical  sign  should  be  examined  as  if  it  were  interesting  or 
obscure.  An  attitude  of  "mild  boredom  bred  of  perfect 
familiarity  with  the  patient's  disorder"  is  cultivated.  If  the 
case  is  exhibited  it  should  be  exhibited  "  as  a  perfect  example  " 
of  the  type  of  case  that  is  cured  in  five  minutes  by  appropriate 
treatment.  "Rapidity  and  an  authoritative  manner  are  the 
chief  factors  in  the  reeducative  process." 

Re  psychoelectric  treatment,  see  Yealland's  book,  pub- 
lished while  this  compilation  was  going  to  press.  Hysterical 
Disorders  of  Warfare,  19 18. 


TREATMENT   AND   RESULTS  783 


Brachial  monoplegia  following  use  of  sling  after 
bruise  or  wound.  Technique  of  electrical  sug- 
gestion and  rapid  reeducation. 


Case  564.     (Adrian  and  Yealland,  June,  191 7.) 

Adrian  and  Yealland  give  the  following  typical  case  of 
paralysis  of  the  arm  as  a  very  frequent  and  very  curable 
form  of  war  neurosis,  occurring  as  a  rule  after  a  slight  wound 
or  bruise  necessitating  the  use  of  a  sling.  The  patient,  hav- 
ing received  a  slight  wound  of  the  forearm,  for  months  had 
a  useless  arm,  which  he  could  move  but  slightly  at  the 
shoulder  on  exerting  a  superhuman  effort.  Occasionally  he 
could  flex  the  fingers  through  a  small  angle.  There  was 
complete  anesthesia  of  the  hand  and  arm  of  long-glove  type. 
This  anesthesia  was  not  complained  of,  and  might  not  be 
noticed  until  suggested  to  the  patient  by  the  physician.  It 
Is  well  to  elicit  the  anesthesia,  however,  in  view  of  the  treat- 
ment to  be  applied.  There  was  no  wasting  of  muscles;  the 
sensory  loss  was  typical  of  hysterical  anesthesia;  nor  could 
the  whole  arm  have  been  involved  by  an  injury  that  did  not 
affect  the  upper  arm  and  shoulder. 

The  patient  was  told  that  he  was  very  lucky  to  have  come 
off  with  such  a  slight  Injury ;  his  arm  was  to  be  set  right  in  five 
minutes  by  the  application  of  a  special  form  of  electricity. 
He  was  then  made  to  sit  on  a  large  pad  electrode  connected 
with  an  induction  coil;  the  other  terminal  is  connected 
with  a  wire  brush.  The  first  effect,  he  was  told,  would  be 
the  return  of  feeling  in  the  forearm;  power  would  return 
with  the  feeling.  The  wire  brush  with  a  fairly  strong  cur- 
rent was  drawn  downwards  over  the  forearm  from  elbow  to 
wrist.  He  was  told  that  he  could  now  feel  as  far  as  the 
wrist,  and  a  pin  was  used  to  convince  him  that  he  could  thus 
feel.  If  he  had  not  felt  the  pinprick,  the  current  would  have 
been  Increased  In  strength  until  he  could  feel.  The  hand  was 
now  treated  In  the  same  way. 

He  was  now  told  that,  as  feeling  had  returned  to  the  arm, 
the  power  of  movement  would  be  restored  shortly.     Adrian 


784  TREATMENT  AND  RESULTS 

and  Yealland  remark  that  laymen  seem  to  consider  that  loss 
of  power  and  loss  of  feeling  are  inseparably  connected.  The 
electrode  was  now  used  to  produce  contraction  in  the  mus- 
cles. Under  these  circumstances,  the  arm  will  be  used  hesi- 
tatingly, with  an  appearance  of  great  effort;  but  the  patient 
is  nevertheless  convinced  that  power  is  returning. 

"Rapid  reeducation  follows  at  once.  He  is  given  no 
time  to  think,  but  urged  to  move  the  arm  more  and  more 
strongly,  to  grip  the  physician's  hand,  to  flex  and  extend  the 
elbow,  etc.,  and  the  pressure  is  not  relaxed  until  the  whole 
arm  has  returned  to  its  normal  vigor.  If  recovery  is  station- 
ary, faradization  is  repeated  with  stronger  and  stronger  cur- 
rents. If  it  seems  as  though  he  might  relapse  on  leaving  the 
hospital,  he  is  told  that  this  is  very  unlikely,  but  that  if  it 
should  occur,  he  should  report  sick  at  once  and  come  back 
for  treatment  with  a  current  far  stronger  than  that  already 
used." 

Adrian  and  Yealland  claim  that  they  have  applied  their 
combination  of  suggestion  and  reeducation  in  more  than  250 
cases  (including  82  cases  of  mutism,  34  of  deafness,  18  of 
aphonia,  37  brachial  or  crural  monoplegia,  46  paraplegia, 
16  hemiplegia,  and  18  of  non-organic  gait  disturbance),  and 
that  although  a  majority  of  the  cases  have  been  of  several 
months'  standing,  treatment  has  been  almost  immediately 
successful  in  at  least  95  per  cent  of  the  cases. 


TREATMENT   AND   RESULTS  785 


Exposure  in  the  retreat  from  Mons:  Persistent 
hysterical  sciatica.  Treatment  by  faradism  and 
verbal  suggestion. 


Case  565.     (Harris,  1915.) 

A  soldier  developed  pains  about  the  hips  and  down  the 
right  thigh  after  getting  wet  through  in  the  retreat  from 
Mons,  August,  1914.  He  was  treated  for  a  period  of  nine 
months  in  various  convalescent  homes  and  military  hospitals, 
incidentally  receiving  forty  baths  at  Droitwich.  He  hobbled 
on  a  stick,  leaning  upon  the  left  leg  and  dragging  the  right 
stiffly.     The  thigh  was  tender  and  hyperesthetic. 

The  proper  treatment  of  cases  of  hysteria,  according  to 
Harris,  is  strong  faradism,  applied  by  a  small  electrode  or 
wire  brush  to  the  moistened  skin.  The  stimulus  is  made 
powerful  enough  to  force  the  patient  to  admit  that  he  feels. 
The  theory  is  that  the  powerful  stimulation  "breaks  down 
the  psychical  auto-inhibition  which  produces  the  hysterical 
anesthesia." 

Faradism  is  only  the  first  phase  of  the  treatment.  Verbal 
suggestion  follows.  Building  on  the  basis  of  the  feeling  pro- 
duced by  the  faradism  or  on  the  basis  of  the  ocular  evidence 
of  motion  in  the  hitherto  paralyzed  muscles,  the  patient  is 
informed  that  the  electricity  will  now  be  more  and  more 
strongly  felt  and  that  he  will  be  cured  in  a  few  minutes. 

The  two  elements  in  the  therapy,  then,  are:  encouraging 
verbal  suggestion  and  the  suggestion  afforded  by  the  para- 
phernalia of  a  complex  looking,  noisy  machine.  The 
knowledge  on  the  part  of  the  patient  that  a  powerful  and 
mysterious  stimulus,  namely,  electricity,  is  being  employed 
is  a  third  element  of  suggestion. 

Persistent  hysterical  sciatica,  such  as  that  of  the  present 
case,  may  require  prolonged  treatment.  In  this  instance,  the 
man  was  completely  cured  in  five  minutes,  so  that  he  was 
made  able  to  run  across  the  room.  He  said  he  would  now  be 
able  to  go  back  to  the  front,  and  wondered  why  he  could  not 
have  been  cured  before. 


786  TREATMENT  AND  RESULTS 


Prognosis  of  intensive  reeducation  in  reflex 
(physiopathic)  disorder  —  complete  recovery  (ex- 
cept for  the  hysterical  fraction  of  the  disease)  not 
expected. 


Case  566.     (Vincent,  1916.) 

A  young  soldier  was  superficially  wounded  in  the  left  knee, 
in  August,  1 9 14.  A  year  later,  he  showed  amyotrophy  of  the 
left  calf,  which  measured  2.5  cm.  less  than  the  right,  a  weak 
slow  Achilles  reflex  on  the  left  side,  cyanosis  and  hypothermia 
of  the  left  foot,  weakness  and  limitation  of  movements  in  the 
left  foot,  with  slight  contracture  In  flexion  of  leg  upon  thigh. 

Thenceforward  and  for  eight  months,  this  soldier  was  sub- 
mitted at  the  Tours  Centre  to  intensive  reeducation.  For 
two  hours  every  day  upon  prescription  he  walked,  ran,  and 
hopped  upon  the  left  leg.  In  September,  19 16,  after  twelve 
month's  training,  there  was  a  certain  Improvement  In  his 
disorder.  The  leg  was  now  completely  extended  upon  the 
thigh,  and  the  amplitude  in  the  movement  of  the  foot  was 
almost  normal;  but  the  amyotrophy,  vasomotor  disorder 
and  certain  electrical  disturbances  remained  quite  unchanged. 
The  man  himself  recognized  that  his  status  was  greatly  Im- 
proved, but  he  could  not  walk  more  than  four  or  five  kilo- 
meters without  great  fatigue. 

In  view  of  the  inferior  results  of  reeducation  in  some  of 
these  cases,  should  any  attempt  at  all  be  made  to  reeducate? 
Vincent  thinks  that  that  should  be;  but  that  it  should  be 
borne  in  mind  that  sometimes  no  results  may  be  obtained. 
If  the  reflex  disorder  (In  the  Babinski  sense)  is  minimal  and 
the  chief  difficulty  is  hysterical,  then  sometimes  the  man  may 
go  back  to  service  after  reeducation ;  but  In  Intense  examples 
of  reflex  (physiopathic)  disorder,  invaliding  has  often  proved 
necessary. 

Re  values  of  intensive  reeducation,  Vincent's  technique 
and  results  have  logical  resemblances  to  those  of  Yealland 
and  of  Kaufmann.  Vincent  established  in  the  9th  district 
neurological  center  a  method  of  Intensive  reeducation  which 


TREATMENT   AND   RESULTS  787 

is  particularly  suited  to  old  hysterical  cases.  He  divides 
the  treatment  into  three  stages:  First,  the  stage  called  by 
the  poilu  by  the  picturesque  name  of  torpillage;  secondly, 
the  stage  of  fixation ;  thirdly,  the  stage  of  training.  Accord- 
ing to  Roussy  and  Lhermitte,  there  are  few  cases  at  the 
front  suitable  for  the  treatment  of  Clovis  Vincent,  which  is 
especially  devised  for  the  old  cases.  See  under  Case  574 
for  further  details  of  Vincent's  treatment. 

Re  prognosis  of  the  physiopathic  disorder,  there  has  been 
some  controversy  in  France.  See  discussion  under  Case  530. 
Re  suitable  treatment  for  physiopathic  disorders,  Babinsld 
and  Froment  suggested  the  application  of  heat.  The  warm 
bath  test  is  also  of  value  In  diagnosis.  BablnskI  and  Fro-, 
ment  claim  progressive  Improvements  with  hot  baths,  hot 
air  douches,  and  light  baths  —  but  counsel  great  prudence. 
The  improvement  is  never  rapid. 

\ 


788  TREATMENT  AND  RESULTS 


Wound  of  calf ;  operations :  hysterical  contracture 
with  "physiopathic"  features.  ''Brutally  con- 
quered "  by  reeducation. 


Case  567.     (Ferrand,  March,  1917.) 

A  French  infantryman,  class  of  191 2,  was  wounded,  May 
12,  191 5,  in  the  upper  third  of  the  right  calf.  His  posterior 
tibial  artery  had  to  be  ligated.  In  a  few  weeks  the  wound 
was  healed,  but  he  began  to  walk  badly,  presenting  a  con- 
tracture of  the  calf  with  retraction  of  the  tendo  Achill  is. 

Toward  the  last  of  191 5  a  surgeon  under  the  impression 
that  the  disease  was  organic  cut  the  tendo  Achill  is  but  the 
soldier  could  not  walk  any  better.  As  he  could  not  take  the 
position  of  equinism,  he  semiflexed  his  knee  and  walked  upon 
a  crutch. 

Another  surgeon  was  now  found  to  perform  a  tenotomy  on 
the  flexors  of  the  leg  and  put  the  patient  in  a  plaster  cast  to 
correct  the  flexion  and  immobilize  in  extension.  This  second 
operation  was  in  July,  1916.  The  patient  now  walked  with- 
out a  crutch. 

He  was  then  sent  to  a  neurological  center,  Dec.  8,  1916, 
walking  on  two  canes,  right  leg  in  forced  extension  on  thigh, 
in  permanent  and  absolute  contracture.  All  movements  ex- 
cept leg  flexion  could  be  executed,  though  slowly  and  weakly; 
but  positive  movements  were  impossible,  except  flexion  of 
the  knees.  There  was  no  sensory  disorder.  Reflexes  were 
normal  save  that  the  leg  reflexes  were  a  little  stronger  on  the 
affected  side,  and  the  patellar  reflex  on  that  side  was  nullified 
by  the  contracture.  Electrical  reactions  proved  normal. 
There  were  marked  trophic  disturbances  of  the  right  foot  and 
of  the  lower  third  of  the  lower  leg.  There  was  a  certain 
amount  of  edema,  cyanosis,  coldness  and  thickening  of  skin; 
marked  muscular  over-excitability  of  the  distal  extremity  of 
the  leg.  In  short,  Ferrand  was  here  dealing  with  a  case  of 
Babinski's  group  of  the  so-called  physiopathic  cases.     The 


TREATMENT   AND    RESULTS  789 

man  was  somewhat  feeble-minded,  and  anxious  and  a  trem- 
bling suppliant  for  cure. 

He  was  put,  December  15,  in  a  reeducation  room  and  by 
means  of  fatigue,  induced  by  violent  physical  exercises,  was 
(Ferrand  states)  ''brutally  conquered."  The  contracture 
after  a  half  hour  of  physical  movement  of  flexion  and  ex- 
tension of  the  leg  ceased.  The  patient  was  shown  how  he 
could  himself  both  flex  and  extend  the  limb  himself;  he  was 
then  caused  to  do  this  spontaneously.  These  active  move- 
ments were  aided  and  at  times  provoked  by  somewhat  pain- 
ful galvanic  discharges.  The  patient  then  walked  slowly, 
and  flexed  both  knees  to  the  maximum.  He  was  cured  after 
a  treatment  of  2^  hours.  There  were,  of  course,  some  (sur- 
gical) intra-articular  adhesions  in  the  knee  and  it  was  neces- 
sary for  the  patient  to  break  these  adhesions.  An  X-ray 
had  shown  the  bone  to  be  intact.  A  slight  hydrarthrosis 
developed  the  next  day,  but  a  few  days  later  he  was  able  to 
walk  as  well  as  anyone.  For  five  weeks  he  followed  a  train- 
ing platoon  in  the  reeducation  work  and  was  evacuated, 
January  23,  191 7,  to  his  station,  though  he  had  entered  the 
neurological  center  with  the  idea  that  he  was  to  be  invalided 
with  a  pension. 

He  had  a  few  relics  of  physiomotor  disorder  when  he  left, 
including  the  abnormal  delicacy  of  skin  and  muscular  over- 
excitability  above  mentioned.  On  the  basis  of  this  and  sim- 
ilar cases  Ferrand  believes  that,  although  the  physiopathic 
group  of  Babinski  exists,  it  does  not  signify  a  separate  clinical 
syndrome  and  the  occurrence  of  physiopathic  symptoms  does 
not  contraindicate  psychotherapy. 
Re  this  controversy,  see  remarks  under  Case  530. 


790  TREATMENT   AND   RESULTS 


Shell-shock :  Paraparesis.     Cure  by  electricity. 


Case  568.     (TuRRELL,  January,  1915.) 

Turrell,  in  a  paper  on  electrotherapy  at  a  base  hospital, 
narrates  a  case  of  spinal  concussion  which  rapidly  yielded  to 
the  persuasive  influence  of  Bergonie's  machine  for  electri- 
cally provoked  exercises.  Turrell  grants  that  such  a  rapid 
cure  would  probably  be  attributed  to  suggestion,  but  thinks 
that  the  term  demonstration  might  be  preferred  on  account  of 
the  vigor  and  amplitude  of  the  muscular  contractions  excited. 

This  soldier  was  driving  an  ammunition  wagon  at  the 
front,  when  a  shell  exploded  under  the  wagon,  killing  one 
horse  and  severely  wounding  the  other.  The  patient  him- 
self was  blown  into  the  air,  fell,  dragged  himself  to  a  trench 
where  he  lay  all  night,  and  found  himself  in  the  morning 
unable  to  walk  or  stand.  He  recalls  that  pins  were  stuck 
into  his  legs  by  the  examining  medical  ofhcer  and  that  they 
produced  no  sensation.  When  he  was  finally  brought  to  the 
Third  Southern  Medical  Hospital,  he  was  unable  to  draw  up 
or  move  his  legs,  or  to  stand  up  (yet  neurologically  normal). 

After  a  few  days'  rest  In  bed,  he  found  himself  able  to 
walk  a  few  steps  with  assistance,  and  was  then  transferred  to 
the  Radcliffe  Infirmary  for  electrical  treatment.  This  treat- 
ment consisted  in  electrically  provoked  exercises  to  the  back 
(positive)  and  seat  and  thighs  (negative).  He  was  able  to 
walk  back  to  his  ward,  leaning  on  a  wheelchair.  Next  day 
he  walked  to  the  electrical  department  with  sticks,  and  after 
the  exercises  were  repeated,  he  was  found  able  to  walk  with- 
out assistance.  On  the  third  day,  the  Morton  wave  current 
was  applied  to  the  back,  to  clear  up  any  persistent  stiffness. 
The  patient  was  then  discharged  on  sick  furlough. 

Re  the  Morton  wave  and  similar  applications  of  electricity, 
Zeehandelaar  speaks  of  a  high  frequency  hall  fitted  up  at 
Berlin.  Touching  the  walls  of  the  hall  with  the  finger  elicited 
a  powerful  spark.  The  scheme  appeared  to  be  on  a  commer- 
cial basis,  and  It  was  proposed  to  start  similar  institutions 
for  poor  metabolism  and  neuroses  in  other  cities. 


TREATMENT  AND   RESULTS  79 1 


A  year's  field  service,  gunshot;  typhoid  fever: 
Astasia-abasia :  Lourdes-like  cure:  Residual 
amnesia. 


Case  569.     (Voss,  November,  191 6.) 

A  soldier  in  service  from  the  outbreak  of  war,  shot  in 
September,  19 15,  afterward  suffering  from  fainting  spells, 
was  treated  in  several  hospitals.  He  developed  a  typhoid 
fever  at  Lindau,  which  was  at  first  taken  for  hysterical  fever. 
Eventually  he  came  to  the  observation  of  Voss,  unable  to 
stand  and  falling  hysteria-wise  if  compelled  to  walk. 

Thorough  examination  was  made.  It  was  emphatically 
explained  to  him  that  there  could  be  no  reason  why  he  should 
not  stand  or  walk. 

A  miracle  occurred.  From  the  second  day  of  his  hospital 
stay  he  not  only  walked  about  but  began  to  polish  doors  and 
windows  with  inexhaustible  strength. 

But  when  he  was  about  to  be  told  that  he  must  now  be 
looked  upon  as  well,  the  miracle  was  not  so  manifest.  It 
now  transpired  that  he  had  serious  gaps  of  memory  and 
disorders  in  recognition,  a  sphincter  disorder  and  ever  since 
his  typhoid  incontinence  with  fluid  feces. 

In  short,  waking  suggestion  had  caused  a  very  prominent 
symptom  to  disappear,  but  the  total  personality  remained 
sick.  According  to  Voss,  the  procedures  of  Kaufmann  are 
dubious  just  because  they  cannot  stand  the  test  of  time. 
Yet  so  far  as  the  cure  of  this  man's  astasia-abasia  was  con- 
cerned, it  was  not  at  all  unlike  the  cures  wrought  at  Lourdes. 

Re  miracles  of  this  sort,  see  cases  of  Colin  Russel  (503 
and  504)  as  well  as  those  of  Veale  (511  and  512).  Voss' 
arguments  run  parallel  with  the  contentions  of  various  per- 
sons that  the  miracle  cures  (such  as  those  by  anesthesia, 
electric  suggestion,  and  hypnosis),  do  not  get  sufficiently  to 
the  bottom  of  the  affections  in  question.  Buzzard,  in  the 
preface  to  Yealland's  book  on  the  Hysterical  Disorders  of 
Warfare,  remarks  that  the  question  of  the  ultimate  prognosis 
in  cases  thus  suddenly  cured  must  be  left  unanswered. 


792  TREATMENT    AND   RESULTS 


Dysbasia  after  a  fall:    **  Kaufmaim  "  cure  in  six 
weeks. 


Case  570.     (ScHULTZE,  August,  191 6.) 

Severe  dysbasia,  due  to  monoplegia  of  the  right  leg  of 
sudden  origin  (a  fall),  was  variously  treated  64  weeks  with- 
out effect. 

July  15,  1916,  the  patient  walked  in  on  a  stick,  and  fell 
down  on  trying  to  walk  without.  August  i,  191 6,  at  9 
o'clock,  he  was  rapidly  examined:  Anesthesia  to  pain  and 
temperature ;  inability  to  lift  right  foot ;  the  right  knee  could 
be  lifted  about  a  hand-breadth  above  the  body  if  the  foot 
was  supported. 

At  9:10,  a  small  electrode  was  applied:  sensibility  be- 
came normal  at  once.  Second  application:  leg  raised  much 
better.  The  man  was  told  that  he  was  better  and  that  his 
hand  could  be  put  under  the  heel.  Third  application:  Leg 
raised  8  cm.  The  patient  showed  pleasure  at  the  advance. 
Fourth  application  (slightly  increased  strength) :  Patient 
able  to  stand  and  to  lift  knee  with  flexion  at  135°  while 
standing.  Walking  exercises  under  direction.  At  9:30,  five 
minutes  recess  was  given  for  fatigue,  whereupon  the  exer- 
cises were  taken  up  again  and  transition  made  from  station- 
ary running  to  walking  without  aid  as  well  as  a  variety  of 
other  associated  acts  (grasping  handkerchief  instead  of 
physician's  hand,  and  the  like).  The  patient  became  ex- 
hausted after  8  or  9  minutes  running  about,  and  another 
pause  was  given. 

The  large  brush  electrode  with  stronger  current  was  now 
given  to  the  back  and  to  the  back  of  the  right  leg.  Practice 
in  slow  walking,  lifting  knee,  and  holding  hip  joint  firm. 
The  patient  became  tired,  but  remained  very  willing.  Ex- 
ercises in  pulling  on  stockings,  in  climbing  stairs  —  the 
whole  concluded  at  10  o'clock,  whereupon  it  was  found  that 
the  patient  could  walk  alone  for  a  distance  of  50  meters. 
The  patient  was  a  very  suggestible  one.  It  was  striking  that 
the  patient  in  the  time  between  9:35  and  9:40  minutes  could 


TREATMENT  AND  RESULTS  793 

walk  better  on  the  right  (that  is,  the  previously  affected  leg) 
than  upon  the  left.  Rest  in  bed  and  phenacetine  were 
ordered,  with  the  suggestion  that  in  the  morning  he  would 
walk  much  better.  He  became  irritated  after  the  treatment 
but  grew  quieter  in  the  afternoon. 

On  August  3,  he  was  found  able  to  walk  well,  better  when 
not  observed  than  when  observed.  August  5,  he  complained 
that  his  leg  was  worse  and  used  a  cane,  without  permission. 
He  was  roundly  scolded  by  the  physician  and  threatened 
with  being  sent  to  bed  if  he  did  not  practice  earnestly.  Au- 
gust 7,  he  was  better,  and  confessed  that  he  could  not  walk 
as  well  on  command  as  he  could  alone;  the  exercises  were 
nothing  but  a  fraud  and  he  could  go  out  and  beat  everything 
up  {alles  zerschlagen)  if  he  did  not  have  to  carry  out  such 
exercises. 

August  15,  he  was  much  better,  quiet,  and  satisfied.  The 
lameness  was  practically  gone.  August  30,  there  was  no 
sign  of  lameness,  even  when  he  was  observed.  According  to 
Schultze,  the  Kaufmann  method  is  not  merely  an  Erb  tradi- 
tion, and  rather  special  measures  need  to  be  taken  in  execut- 
ing it. 

Re  Kaufmann's  cure,  Imboden  sums  up  this  "highly  logi- 
cal and  brutal  method"  as  a  method  in  which  powerful 
electric  shocks  and  loud  military  orders  to  perform  certain 
exercises  secure  results.  Imboden  suggests  that  relapses 
may  follow,  sometimes  on  the  slightest  provocation.  Mann 
states  that  Kaufmann's  method  of  suggestion  and  electric 
shock  forms  very  good  treatment;  yet  Mann  states  there 
have  been  two  deaths  under  this  treatment:  in  both  in- 
stances there  was  an  enlarged  thymus  at  autopsy.  A  better 
technique,  especially  the  use  of  the  faradic  current  alone, 
might  have  avoided  these  deaths.  Mann  himself  prefers  to 
Kaufmann's  Ueberrumpelung  milder  methods,  such  as  rest. 
Kaufmann  keeps  up  the  sitting  until  the  man  is  cured,  even 
if  it  takes  two  hours  of  electricity  and  staccato  commands. 
For  similar  persistance,  see  the  treatment  by  induced  fatigue 
of  Reeve  (Cases  489-493). 


794  TREATMENT  AND  RESULTS 


Wound  of  shoulder:  Heterosuggestion  of  BRA- 
CHIAL paresis.  Electrical  suggestion  of  muscu- 
lar power.     Recovery  in  five  days. 


Case  571.     (Hewat,  March,  191 7.) 

A  reenlisted  soldier  arrived  at  the  Royal  Victoria  Hospital, 
as  a  case  of  ulnar  paralysis.  He  had  been  wounded  in  France 
six  months  before  by  a  bullet  which  passed  through  the 
fleshy  part  of  the  shoulder,  above  the  middle  third  of  the 
clavicle.  Power  in  the  right  arm  gradually  diminished; 
yet  two  months  after  the  wound  he  seemed  fit  enough  to  be 
sent  to  Egypt.  The  paresis  developed,  and  in  a  month's 
time  he  was  invalided  home.  He  had  been  unable  to  use  a 
rifle  for  months. 

The  healed  bullet  wounds  were  found  about  the  region  of 
the  brachial  plexus.  The  patient  was  sure  the  bullet  had 
damaged  the  nerves  in  that  region.  The  right  arm  and  hand 
were  limp  and  over-inclined  to  blueness,  and  the  muscles 
were  flabby.  Active  movements  of  all  sorts  could  be  carried 
out  with  the  arm  but  not  against  resistance.  There  was  a 
definite  anesthesia  and  analgesia  throughout,  and  responses 
to  touch  and  pain  stimuli  were  irregular. 

By  way  of  treatment,  the  patient  had  the  muscles  of  the 
paretic  arm  stimulated  electrically,  and  at  the  same  time 
he  was  told  that  no  nerve  of  the  neck  had  been  injured.  He 
was  greatly  surprised  to  see  his  palsied  arm  move  vigorously. 

A  milk  isolation  treatment  in  bed  behind  screens  was 
adopted,  whereat  the  patient  was  angry,  looking  upon  the 
Weir- Mitchell  treatment  as  punishment. 

On  the  next  day,  another  electrical  application  secured 
complete  power  in  the  arm  and  abolished  sensory  disturbance. 
Three  days  later  the  man  went  back  to  full  duty.  According 
to  Fergus  Hewat,  someone  doubtless  had  suggested  to  this 
patient  that  he  had  received  a  nerve  injury.  He  had  be- 
come obsessed  thereby  and  developed  a  typical  functional 
paralysis.  This  was  a  "  cortical  misinterpretation,"  which 
disappeared  upon  forcible  demonstration  of  the  error. 


TREATMENT   AND   RESULTS  795 


Exposure ;  intestinal  disorder  in  weakminded  neu- 
ropath: Camptocormia  and  hysterical  paraplegia: 
Cure  by  psycho-electric  treatment. 


Case  572.  (RoussY  and  Lhermitte,  191 7.) 
A  French  territorial,  45,  was  observed  at  the  Centre  Neuro- 
logique,  August  28,  1916.  He  was  a  victim  of  hysterical 
paraplegia  with  tripod  gait.  There  was  a  stiffness  of  the 
lumbar  vertebral  column  which  had  lasted  six  months. 
This  paraplegia  had  begun  spontaneously  after  cold  and  an 
attack  of  diarrhoea  followed  by  constipation.  The  campto- 
cormia and  disorder  of  gait  had  come  on  gradually  in  the 
ambulance.  He  came  on  a  stretcher.  He  was  found  to  be 
able  to  walk  with  great  difhculty  by  leaning  both  hands  on  a 
cane.  The  two  legs  were  tremulous  in  a  pseudospastic  gait. 
The  next  day,  after  a  single  psycho-electric  treatment,  cure 
was  complete.  This  patient  was  mentally  somewhat  weak 
and  a  constitutional  neuropath.  He  was  discharged,  cured, 
October  20,  191 6. 


Brachial     monoplegia,    hysterical     (or    feigned?). 
Found  able  to  descend  ladder  with  arms  only. 


Case  573.     (Claude,  July,  1916.) 

Claude  had  a  case  of  a  soldier  with  right-sided  brachial 
monoplegia,  which  had  lasted  for  18  months  and  defied 
efforts  to  cure.  There  was  a  question  of  simulation,  and 
Claude  handed  the  case  over  to  Vincent. 

The  case  came  on  service,  June  20,  and  was  seen  June  21. 
He  was  then  treated  and  found  able  to  descend  a  ladder  ap- 
plied to  a  wall  with  the  help  of  his  arms  only.  On  June  24, 
he  was  found  able  to  lift  a  weight  of  10  kilos,  and  could  now 
write  with  the  right  hand,  although  he  had  been  writing 
only  with  his  left.  This  man  had  looked  like  a  simulator  to 
many  physicians.  He  may  have  been  a  simulator  or  an 
hysteric.     In  any  case,  he  was  cured. 


796  TREATMENT  AND  RESULTS 


Vicissitudes  of   treatment  of   hysterical   brachial 
monoparesis  (shell  burial). 


Case  574.     (Vincent,  July,  1917-) 

A  French  private  was  buried  in  a  trench  upon  the  explosion 
of  a  large  shell,  November,  1914.  He  said  he  had  had  a 
"  fracture  of  the  occiput  "  and  had  fainted  away  without 
regaining  consciousness  for  several  hours. 

He  was  evacuated  to  Dunkirk,  then  Saint  Nasire,  and  then 
to  Sables-d'Olonne.  He  showed  no  paralysis  or  paresis  of 
limbs.  During  the  first  month,  he  had  violent  pains  in  the 
head,  spells  and  vomiting.  There  was  a  slight  aphasic  dis- 
order. He  was  treated  by  cupping  upon  the  head  and  by 
applications  of  ice. 

After  the  visit  of  the  inspector  general,  he  was  sent  to 
Nantes  to  be  trephined.  Dr.  Mathieu  regarded  an  oper- 
ation as  useless.  He  was  treated  with  bromides  and  the 
faradic  current  by  Miraille,  applied  to  the  right  arm,  which 
had  become  paretic. 

June,  191 5,  he  started  on  a  three-months  convalescent  leave 
in  Paris. 

From  October  to  December,  he  had  electric  treatment  at 
the  Grand- Palais. 

December,  1915,  he  went  to  the  Salpetriere  under  P.  Marie, 
where  he  was  given  electric  treatment. 

January  19 16,  he  went  to  Maison- Blanche  under  Laignel- 
Lavastine,  where  he  was  given  electricity  4I  months. 

April  4  he  went  back  to  his  depot. 

Presented  to  the  invaliding  board,  May  11,  at  Decize, 
he  was  sent  to  the  neurological  center  at  Bourges.  He  was 
there  given  massage  and  movements.  Upon  entrance  he  had 
a  functional  inactivity  of  the  right  arm.  He  should  have 
been  cured  a  long  time  before  by  the  therapeutics  employed. 
He  was  then  sent  to  Vincent  at  the  neurological  center  at 
Tours  for  special  motor  reeducation.  Vincent  found  almost 
complete  functional  incapacity  of  the  right  arm,  without 
atrophy,  with  normal  reactions,  no  R.  D.,  and  normal  ar- 


TREATMENT   AND   RESULTS  797 

terial  pressure.  June  26,  1916,  the  patient  was  able  to 
write,  although  slowly.  He  could  sign  a  letter,  and  could 
lift  a  weight  of  10  kilos. 

The  details  of  Vincent's  method  mentioned  under  Case  566 
are  pursued,  to  use  his  own  words,  with  methodical  ruthless- 
ness.  This  form  of  reeducation  consists  in  maneouvres  that 
make  the  patients  yield  despite  themselves.  The  galvanic 
current  is  used  to  force  a  man  to  react  voluntarily  or  auto- 
matically. See,  for  example,  Claude's  case  of  a  hysterical 
brachial  monoplegic  (Case  574)  found  able  to  descend  a 
ladder  with  the  use  of  his  arms  only.  After  the  physician's 
victory  is  secured,  then  a  sort  of  consolidation  must  be 
obtained  by  means  of  the  execution  of  certain  movements  on 
the  part  of  the  patient  for  an  hour  or  two.  As  another 
factor  In  the  situation  set  up  by  Clovls  Vincent,  is  the 
enthusiasm  generated  in  the  moral  atmosphere  in  which  the 
cure  takes  'place.  Mott  has  also  insisted  upon  this  atmos- 
phere of  cure,  which  Mott  believes  is  in  part  responsible 
for  the  good  results  of  Adrian  and  Yealland.  Roussy  and 
Bolsseau,  at  Sallns,  started  out  with  a  process  similar  to  that 
of  Vincent,  with  a  preliminary  period  of  isolation.  Roussy 
also  uses  the  faradic  current  instead  of  the  galvanic  (see 
remarks  of  Mann  concerning  deaths  with  the  Kaufmann 
method  in  Germany,  under  Case  570).  Vincent's  three 
stages  are  given  in  Chart  19,  page  897. 


798  TREATMENT    AND    RESULTS 


Struck  by  shell  fragment ;  run  over  by  shell ;  paresis 
and  regionary  sense  disorder.  Treatment  by  re- 
education. 


Case  575.     (BiNSWANGER,  July,  1915-) 

A  German  subaltern  officer,  27,  was  wounded  September 
25,  1914,  in  a  battle  in  France.  He  gave  the  following  ac- 
count : 

"  We  had  been  firing  without  interruption  four  days,  and 
then  were  sent  back.  While  going  back  from  cover  we  were 
under  shell  fire.  Three  or  four  horses  fell.  I  got  a  glancing 
blow  from  a  shell  fragment  in  the  back  of  the  head,  and  fell 
down.  I  was  not  quite  unconscious.  I  tried  several  times 
to  get  up,  but  I  could  not,  for  I  had  very  bad  pains  in  the 
head  and  a  confused  feeling  in  it,  too.  I  remember  also  that 
a  wheel  ran  over  my  foot,  and  that  I  got  a  sharp  blow  in  the 
chest.  Then  I  was  unconscious  for  about  an  hour.  When 
I  awoke,  there  were  two  comrades  busy  over  me  and  they 
pulled  me  back  of  the  firing-line.  Then  I  got  to  a  field 
hospital." 

The  man  arrived  at  the  nerve  hospital  (Jena),  October  8, 
1 9 14,  with  insomnia,  respiratory  disturbance,  sudden  per- 
spiration, feelings  of  cold  in  the  right  foot,  and  poor  appetite. 
He  had  had  nausea  for  a  few  days.  Lungs  and  heart  proved 
normal.  X-ray  of  the  right  foot  showed  normal  relations. 
The  man  was  a  small,  powerfully-built  man,  well  nourished, 
with  lively  reflexes,  especially  the  knee  reflexes,  of  which  the 
right  was  greater  than  the  left;  slight  patellar  clonus,  right; 
left  plantar  reflex  greater  than  right;  segmental  disorder  of 
touch  and  pain  sense  in  the  right  foot  and  lower  leg,  a  zone 
of  analgesia  lying  above  the  zone  of  total  anesthesia.  Gait 
was  lame  on  account  of  inability  to  move  the  right  ankle 
joint.     In  walking,  the  right  foot  was  trailed. 

Treatment  was  suggestive  and  supported  by  active  gym- 
nastic exercises,  breathing  exercises,  exercises  in  moving 
the  right  leg,  massage,  faradism  and  local  hydrotherapy. 
The  gait  gradually  improved,   the  cold  feeling  disappeared 


TREATMENT   AND   RESULTS  799 

from  the  right  leg,  disturbances  of  pain  and  touch  sense  dis- 
appeared. The  patient  was  released  on  the  2d  of  February, 
19 1 5,  capable  of  garrison  duty. 

With  respect  to  this  man,  who  was  married,  he  was  from 
a  healthy  family  and  had  healthy  children.  He  is  said, 
however,  to  have  suffered  from  convulsions  for  a  long  time  in 
early  life,  but  thereafter  had  never  been  sick  in  any  way. 
He  was  a  good  student  and  had  been  a  post-office  official 
since  1908.  After  two  years'  military  service,  he  became,  in 
1910,  Unteroffizier- Aspirant.  Later  he  was  advanced  to  his 
subaltern  position  in  the  reserve. 

This  case  seems  to  be  a  characteristic  example  of  seg- 
mental disorder  of  sensations  of  both  touch  and  pain,  com- 
bined with  a  paresis  in  the  same  region.  Mechanical  and 
mental  factors  seem  to  have  been  present,  and  the  case 
belongs  in  what  Binswanger  calls  the  "  hysterosomatic " 
group. 

Re  Binswanger's  so-called  hysterosomatic  group,  he  de- 
fines the  cases  as  having  emotional,  mechanical,  and  toxic 
(gas)  factors.  On  the  whole,  they  are  best  classified  as  a 
kind  of  psychoneurosis.  Binswanger  finds  all  physical  and 
drug  treatment  without  result  except  as  supportives.  He 
has  used  hydrotherapy  and  electrotherapy  with  the  per- 
fectly clear  conception  that  the  procedures  were  of  sugges- 
tive value  only.  In  fact,  Binswanger  had  before  defined 
such  procedures  as  Realsuggestionen  or  material  suggestions. 
Common  verbal  suggestion,  says  Binswanger,  will  work  some- 
times only  when  aided  by  these  material  suggestions.  See 
also  under  Case  576. 


800  TREATMENT   AND    RESULTS 


Post-traumatic  (ANTEBELLUM)  seizures  with  un- 
consciousness :  Further  seizures,  astasia-abasia, 
anesthesias,  following  no  special  period  of  stress  in 
field  service.     Recovery  by  reeducation. 


Case  576.     (BiNSWAXGER,  July,  1915.) 

O.  F.,  26,  healthy,  of  a  healthy  family,  in  military  service, 
1908-1910,  a  miner  in  October,  1912,  had  fallen  into  a  shaft 
from  a  considerable  height,  and  is  said  to  have  been  un- 
conscious for  three  days  and  two  nights  and  to  have  had  some 
sort  of  attack  a  short  time  after  waking.  Later  he  had 
another  attack,  beginning  with  violent  headaches,  running 
from  the  back  to  the  fore  part  of  the  head,  then  dizziness, 
then  a  fall  with  unconsciousness.  The  whole  attack  lasted 
about  four  minutes  and  was  followed  by  feelings  of  extreme 
fatigue. 

It  seems  that  in  the  spring  of  19 13  these  attacks  had  begun 
to  repeat  themselves  two  or  three  times  a  week.  In  the 
spring  of  1914  there  had  again  been  two  attacks  at  an  interval 
of  two  weeks.  They  had  occurred  on  the  way  to  work  and 
had  been  introduced  by  the  same  symptoms  as  before.  They 
lasted  about  half  an  hour. 

He  was  in  the  war  in  France  from  August  6,  1914.  While 
he  was  cooking,  one  day,  in  the  middle  of  September,  he  had 
an  attack  and  this  without  special  occasion.  The  next  at- 
tack occurred  a  little  while  afterwards,  at  the  time  of  an 
assault.  He  said  that  he  fell  down  and  lost  his  senses.  When 
he  came  to  his  senses  again,  he  found  he  could  not  move  his 
legs. 

He  was  taken  to  a  reserve  hospital  in  Germany,  and  while 
there  had  several  attacks  with  unconsciousness  and  spas- 
modic convulsions  —  the  last  on  December  7,  1914.  He  was 
transferred  to  the  Jena  Hospital  on  the  nth. 

The  Jena  examination  had  the  benefit  of  an  Inquiry  con- 
cerning the  case.  It  seems  that  he  had  left  the  field  hos- 
pital in  the  enemy's  country,  in  a  half-conscious  condition, 
and  rode  away  therefrom  aimlessly.     It  was  only  in  Ger- 


TREATMENT   AND   RESULTS  8oi 

many  that  he,  on  his  own  story,  found  his  bearings  again. 
However,  upon  admission  the  disturbance  in  walking  was  very 
noticeable,  since  the  patient  came  hobbling  through  the 
garden  of  the  clinic  with  the  upper  part  of  his  body  bent 
forward,  and  with  the  support  of  two  canes.  The  legs  were 
moved  with  difficulty;  he  seemed  to  take  short,  tripping 
steps,  with  the  toes  dragging  on  the  ground.  His  inability 
to  walk  he  explained  through  the  violent  pains  which  he 
would  feel  in  the  joints  of  the  legs  and  an  extraordinary 
weakness  in  his  legs. 

Physically,  the  man  was  a  tall,  strongly  built  and  well- 
nourished  subject.  Neurologically,  the  knee-jerks  were  some- 
what decreased  and  weaker  on  the  right  side  than  on  the  left ; 
the  Achilles  reflexes  were  lively.  The  plantar  reflex  was  not 
obtainable  on  the  left  side;  decreased  on  the  right.  The 
abdominal  reflexes  were  absent  on  both  sides. 

Most  remarkable  was  the  general  diminution  in  sensi- 
tiveness of  the  skin  to  touch  and  pain,  involving  the  whole 
body,  up  to  the  neck,  where  the  sensory  impairment  abruptly 
ceased  in  a  sharp  line.  The  anesthesia  was  not  everywhere 
complete.  In  a  few  places  pencil  strokes  were  successfully 
localized  and  recognized.  Deep  pin-pricks  were  everywhere 
recognized  as  itching.  When  the  trunk  was  everywhere 
examined  on  both  sides  symmetrically,  a  strong  pressure  with 
a  pin-head  was  felt  as  a  strong  pressure  on  the  right  side,  but 
was  felt  not  at  all  on  the  left  side.  Anesthesia  and  analgesia 
were  total  in  the  legs.  Deep  folds  of  skin  could  be  punctured 
by  needles  without  reaction. 

The  legs  could  be  moved  freely  upon  urgent  request  with 
the  patient  in  dorsal  decubitus.  Still  these  movements  were 
slow  and  difficult,  as  explained  by  the  patient,  on  account  of 
violent  pains  in  the  joints.  If  put  on  his  feet,  he  would  begin 
to  sway  greatly  and  permit  himself  to  slide  down  to  the  ground, 
stating  that  he  was  quite  incapable  of  standing  or  walking 
without  aid.  With  two  canes,  however,  he  could  move  freely 
about  in  the  ward  and  in  the  garden,  and  even  with  consider- 
able speed,  in  a  peculiar,  dragging,  shuffling  way;  in  the 
execution  he  gave  no  sign  of  pain,  contentedly  smoking  a 
cigar  or  a  pipe. 


802  TREATMENT  AND  RESULTS 

While  his  status  was  being  taken  on  admission,  he  became 
suddenly  dull  and  irresponsive,  with  a  staring  look.  He 
could  not  state  his  age  or  his  birthplace.  However,  he  be- 
came clear  shortly,  upon  urging,  and  explained  the  spell  by 
saying  that  the  blood  had  risen  to  his  head.  A  few  days  later, 
he  was  transferred  to  the  psychiatric  division.  He  was 
given  strict  rest  in  bed,  smoking  was  forbidden,  prolonged 
baths  were  used,  and  the  legs  were  massaged.  He  felt  very 
comfortable  in  the  prolonged  baths  and  could  then  move  his 
legs  without  pain. 

A  few  days  later  he  was  taken  out  of  bed  several  times  a 
day,  the  canes  being  removed  immediately,  and  he  was  led 
about  the  day-room  with  the  light  support  of  two  nurses. 
Being  promised  a  cigar  as  a  reward,  he  proved  able  to  walk 
through  the  day-room  supported  by  but  one  nurse.  A  week 
later  the  pains  in  walking  exercises  had  disappeared.  He  had 
become  able  to  walk  alone,  supporting  himself  lightly  along 
the  wall  with  one  hand.     Walking  was  still  uncertain  and  slow. 

December  20,  the  patient  could  stand  free  without  sup- 
port, swaying  slightly;  improvement  became  rapid.  He 
could  shortly  stand  and  walk  without  support  though  his 
walk  was  still  awkward  and  on  a  wide  base  with  knees  pressed 
in  and  body  bent  forward,  soles  were  kept  applied  to  the 
ground.  December  22,  the  patient  could  walk  in  the  garden 
without  aid. 

December  23,  there  was  a  spell  of  great  weariness  and 
complaint  of  being  sick.  The  patient  lay  down  on  the  bed, 
cried  aloud,  and  had  rhythmic  twitchings  and  sudden  move- 
ments with  arms  and  legs.  He  scratched  the  right  half  of  his 
face  with  his  right  hand.  This  spell  lasted  about  a  minute. 
It  was  repeated  in  the  same  way  twice  within  the  half  hour. 

He  had  complete  amnesia  for  these  attacks.  The  pupil- 
lary reactions  were  entirely  normal  in  the  attacks.  He  had 
been  in  bad  spirits  that  day  because  a  Christmas  furlough 
had  been  refused.  The  attacks  provoked  no  bad  conse- 
quences and  his  gait  improved.  He  was  on  furlough  from 
the  30th  to  January  3;  on  the  4th  he  was  transferred  to  the 
nerv^e  department,  but  on  the  12th  of  Januciry  he  was  repri- 
manded for  a  breach  of  discipline,  whereupon  at  9: 15  he  had 


TREATMENT  AND  RESULTS  803 

an  hysterical  attack  with  the  same  coordinate  and  rhythmic 
motions  as  before.  This  attack  lasted  about  20  minutes. 
Two  hours  before  the  attack  he  had  complained  of  weariness 
and  a  boiling-hot  feeling  in  the  body.  Long  walks  were 
taken.  On  February  15  he  began  to  feel  very  happy.  He 
was  informed  that  the  charge  against  him  for  leaving  his 
troop  had  been  dropped.  He  complained  of  sudden  weariness 
and  headache  and  was  markedly  depressed,  but  he  had  no 
hysterical  attack. 

After  February  23  he  took  part  regularly  in  gymnastics, 
executing  the  movements  with  joy  and  without  special  wear- 
iness. He  wanted  to  be  discharged.  He  was  discharged  as 
fit  for  garrison  duty  and  he  has  since  gone  back  to  field  ser- 
vice. 

Re  gymnastics,  Binswanger  holds  that  they  have  a  special 
value  in  overcoming  inner  psychic  resistances  and  weak- 
willed  persons.  The  Realsuggestionen  (see  under  preceding 
case,  575),  such  as  hydrotherapy  and  electrotherapy,  serve 
to  concentrate  the  person's  attention  on  certain  regions. 
These  regional  suggestions  then  smooth  the  way  for  the 
curative  suggestion,  namely,  the  constant  and  monotonously 
repeated  assurance  that  recovery  is  advancing.  At  the  next 
stage,  according  to  Binswanger,  gymnastic  exercises  may  be 
brought  in  to  overcome  hopelessness,  indifference,  or  exag- 
geration of  morbid  feelings.  Binswanger  sets  methodical 
tasks  for  the  attention  and  the  will  (a  so-called  Uebungs- 
iherapie).  If  these  gymnastics  lead  to  mxanifest  improve- 
ment, then  a  proper  educational  therapy  is  prescribed,  which 
is  no  longer  a  merely  exercise  therapy,  but  consists  of 
actions  of  actual  value  in  hospital  routine.  The  convales- 
cents are  gradually  led  to  carry  on  housework,  food  service, 
gardening  (the  latter  under  supervision).  Hospital  clerical 
work  is  a  suitable  occupation.  Re  supervision  over  garden- 
ing, mentioned  by  Binswanger,  Canadian  experience  indi- 
cates that  the  idea  of  supervision  may  be  greatly  extended. 
Particularly  is  this  true  in  vocational  reeducation.  Kidner 
describes  the  functions  of  a  vocational  counsellor,  who  has 
to  have  an  expert  knowledge  of  industry  and  methods  of 
industrial  training,  as  well  as  an  acquaintance  with  the  vary- 


804  TREATMENT   AND   RESULTS 

ing  demands  for  workers,  a  knowledge  of  the  seasonal  varia- 
tions in  employment,  and  a  knowledge  of  occupational  dis- 
eases. Re  occupational  therapy,  Todd  estimates  that  from 
0.5  to  I  per  cent  of  wounded  men  in  France  will  require 
vocational  reeducation.  Occupational  therapy  is  the  proper 
vestibule  to  vocational  training.  He  lists  the  following 
forms  of  treatment  used  in  institutions  for  vocational  reedu- 
cation : 

Active  mechanotherapy. 

Passive  mechanotherapy. 

Galvanic,  static,  and  faradic  electricity. 

Vibration. 

Hot  air  baths  and  blasts. 

Water  baths. 

Colored  light. 

Massage. 

Gymnastics. 
Central  specialized  institutions  such  as  those  developed 
in  France  are  necessary,  and  such  centres  should  be  large 
rather  than  small,  according  to  Todd,  and  should  contain 
not  less  than  200  beds.  Todd  insists  that  work  is,  after 
all,  the  most  important  measure  of  reeducation;  and  Turner, 
speaking  of  the  home  for  neurasthenics  at  Golders  Green, 
says  that  during  a  period  of  three  months  (the  number  of 
the  patients  is  limited  to  100,  and  three  months  is  the  limit 
of  stay),  the  vast  majority,  even  of  the  most  obstinate 
cases,  get  well  through  the  effects  of  sympathy  and  insist- 
ance  upon  work.  Near  Golders  Green  is  the  Maida  Vale 
Hospital  for  nervous  cases,  so  that  in  case  of  need  the  phy- 
sicians there  may  treat  the  patients.  Salmon  gives  a  list 
of  the  occupations  which  are  suitable  for  these  cases. 


TREATMENT   AND   RESULTS  805 


Blown  up  by  shell;  wounds,  right  side,  distention 
and  bloody  urine :  Paresis  of  right  foot  and  spastic- 
ity of  hip ;  later  rectal  and  bladder  incontinence. 


Case  577.     (BiNswANGER,  July,  1915.) 

A  Russian  from  the  Ukraine  was  received  at  the  nerve 
hospital,  Jena,  December  12,  1914.  Through  an  interpreter 
it  was  established  that  he  was  a  peasant,  had  been  under 
shell  fire  in  a  skirmish  at  the  beginning  of  November,  and 
had  been  hurled  (so  he  said)  ij  meters  Into  the  air  without 
loss  of  consciousness.  There  was  a  wound  of  the  right 
shoulder  and  also,  he  thought,  of  the  legs,  from  the  air  pres- 
sure. Becoming  a  German  prisoner,  he  had  been  treated  in 
various  hospitals. 

He  was  a  strong  man  of  medium  height,  with  a  healthy 
complexion.  There  were  two  healed  wounds  of  the  right 
shoulder,  and  near  the  twelfth  spinous  process  a  third  similar 
scar.  There  were  a  number  of  ulcers  and  furuncles  over  the 
OS  sacrum. 

Neufologlcally,  the  knee-jerks  and  Achilles  jerks  could  not 
be  obtained,  and  the  plantar  reflex,  extinct  on  the  left,  was 
weak  on  the  right.  Sensitiveness  to  pain  on  both  sides  was 
lost  from  the  knee  downwards  but  there  was  hyperalgesia  in 
the  thigh.  Inaccurate  statements  In  response  to  tactile  tests 
were  made,  apparently  on  account  of  lack  of  understanding. 
In  lying  down,  there  was  a  slight  restriction  in  the  move- 
ments of  the  legs,  and  active  movements  of  the  joints  of  the 
foot  on  the  right  side  were  'mposslble.  Gait  was  ataxic- 
paretic,  more  markedly  so  right  than  left.  He  could  walk 
only  with  two  canes,  and  during  walking  the  musculature  of 
the  thigh  fell  Into  a  spastic  tension.  The  tongue  deviated 
to  the  left.     There  were  severe  rheumatic  pains  In  the  thighs. 

It  appears  that  some  weeks  before,  this  Russian  soldier 
had  suffered  from  severe  rheumatic  pains  In  both  sides  and 
was  at  that  time  absolutely  unable  to  walk  or  stand.  At 
that  time,  however,  there  was  no  question  of  a  crural  para- 
plegia of  organic  origin,  since  the  man  could  move  his  legs 


8o6  TREATMENT  AND  RESULTS 

well  enough  when  in  dorsal  decubitus.  There  were  no  signs 
of  paralysis  of  the  rectum  or  bladder  at  that  time. 

Treatment  at  Jena  consisted  in  regular  walking  exercises 
with  support  at  the  shoulders.  The  lower  legs  and  feet  re- 
mained weak  and  paretic.     The  decubital  ulcers  disappeared. 

About  the  middle  of  December  rectal  incontinence  began, 
the  stool  being  discharged  without  the  patient's  noticing  it 
while  being  led  to  the  bath.  Later  there  was  incontinence 
of  feces  in  bed.  Pains  in  the  legs  were  constantly  com- 
plained of.  Nevertheless  improvement  in  walking  was  main- 
tained. The  toes  were  dragged  at  every  step  and  the  knee- 
joints  were  thrown  outward  In  walking.  The  musculature  of 
the  lower  legs  was  weak.  Knee-jerks  could  not  be  elicited 
more  than  before.  He  constantly  complained  of  pains  in  the 
knees  and  right  hip.  The  rectal  disorder  did  not  again 
occur  during  January. 

Toward  the  close  of  January,  the  patient's  right  lower  leg 
and  left  foot  would  occasionally  feel  asleep;  both  legs  felt 
cold  and  itched.  In  a  general  way,  however,  the  pains  had 
become  less  marked  than  they  were  at  first.  It  seemed  that 
he  had  no  sensations  at  stool,  and  consequently  had  to  re- 
sort to  the  closet  at  a  definite  time.  Moreover,  urine  was 
discharged  irregularly  and  involuntarily  when  he  coughed. 
It  appears  that  a  few  days  after  receiving  his  wounds  in 
battle,  there  had  been  pains  on  micturition  as  well  as  blood 
in  the  urine,  and  it  appears  that  he  had  been  catheterized. 
It  is  probable  that  he  had  suffered  from  distention,  as  he 
described  his  abdomen,  thighs  and  sex  organs  as  swollen. 

In  February  he  began  to  be  able  to  move  alone  with  two 
canes  through  the  ward,  but  he  moved  his  legs  from  the 
knee  downward  very  little,  and  dragged  them  after  the  rest 
of  the  body.  Upon  galvanic  examination,  the  peroneal  and 
tibial  nerve  trunks  were  found  normally  excitable.  At  this 
time  the  sensibility  situation  had  changed  somewhat,  since 
complete  analgesia  was  present  only  in  the  foot,  and  hypal- 
gesia  had  developed  upon  the  anterior  surfaces  of  the  lower 
legs.  Pin-pricks  were  described  as  touches.  The  posterior 
surface  of  the  left  lower  leg  was  normally  sensitive.  There 
was  an  oblong  stripe  about  3  cm.  long,  beginning  in  the  pop- 


TREATMENT   AND   RESULTS  807 

liteal  space  and  stretching  downward  on  the  left  side.  The 
right  lower  leg  was  entirely  insensitive.  The  posterior  sur- 
faces of  both  thighs  as  far  as  the  gluteal  folds  were  com- 
pletely insensible  to  pain.  The  Wassermann  reaction  of  the 
blood  was  negative.  In  this  condition  the  patient  was  trans- 
ferred to  a  prison  camp  hospital. 

Re  bloody  urine,  see  Section  B,  Case  202.  Re  rectal  in- 
continence, It  might  be  Inquired  whether  this  was  possibly 
functional.  Roussy  and  Lhermltte  devote  a  chapter  to  vis- 
ceral disorders.  They  do  not  list  rectal  incontinence  amongst 
the  disorders  noted  In  this  war,  nor  have  any  cases  of  hys- 
terical anorexia  or  disorders  of  sensation  in  the  intestinal 
tract  been  seen  during  the  war  despite  the  occurrence  of 
these  latter  disorders  In  the  civilian  group.  The  main  diges- 
tive disorder  that  the  war  cases  show  is  vomiting  (see 
Cases  495  and  500) . 


808  TREATMENT   AND   RESULTS 


Emotionality :  Shell  explosion ;  mutism.     Recovery 
by  reeducation. 


Case  578.     (Briand  and  Philippe,  September,  1916.) 

A  plumber,  27,  went  into  the  infantry.  He  was  very 
emotional  and  was  but  a  short  time  in  the  trenches  when  the 
explosion  of  shells  threw  him  into  a  state  of  mutism.  Deaf- 
ness, rather  curiously,  did  not  manifest  itself  for  several 
days.  He  had  to  go  back  on  horseback,  and,  as  he  was  a 
poor  horseman,  slipped  ofT  the  horse,  giving  himself  a  bad 
fright.     When  he  got  up,  he  had  lost  his  hearing. 

He  was  sent  to  several  hospitals  and  finally  to  Val-de- 
Gr§.ce,  in  July,  1915.  He  recovered  hearing  in  fifteen  days, 
but  the  mutism  persisted  several  months.  According  to 
Briand  and  Philippe,  this  Is  a  typical  case,  except  for  the 
duration  of  the  mutism.  The  first  treatment  was  given  this 
patient  August  6.  His  respiration  was  examined  and  tracing 
was  taken.  August  15,  on  the  morning  visit,  he  was  found 
able  to  whistle  very  distinctly  the  first  bars  of  "Au  Clair  de 
la  Lune,"  and  then  began  to  sing  the  first  verses,  articulating 
distinctly,  but  stammering  a  little.  He  was  now  left  to  his 
own  resources,  without  special  exercises,  from  August  15  to 
September  26,  and  completely  lost  the  benefit  of  his  previous 
exercises.  A  week  of  special  treatment  allowed  him  to  re- 
cover speech  again,  enough  to  take  up  every  day  life.  The 
patient  went  out  well. 

The  general  lines  of  the  examination  In  this  case  took  up 
attitude  In  abdomlna  respiration  and  the  question  of  respira- 
tory pauses,  especially  pauses  In  abdominal  respiration, 
which,  in  the  above  case,  were  exaggerated.  Expiration 
was  deficient  and  disordered.  The  normal  adaptations  that 
had  been  established  during  his  childhood  learning  of  speech 
had  failed,  and  the  patient  would  not  have  been  able  by 
himself  to  regain  proper  balance  of  respiration  for  speech. 

The  examination  was  continued  to  learn  the  difficulties  of 
innervation  of  the  muscles  of  phonatlon  whose  proper  deli- 
cacy had  been  lost.     Such  a  patient  Is  a  kind  of  bad  gym- 


TREATMENT  AND   RESULTS  809 

nast,  executing  an  exercise  known  to  be  hard  by  contracting 
all  the  muscles  of  the  region,  both  the  antagonist  and  the 
agonist  muscles.  Reeducation  must,  therefore,  endeavor  to 
sweep  away  the  contractions  that  block  sound.  Then  the 
patient  must  be  made  to  perform  the  contractions  necessary 
in  phonation  and  articulation  unconsciously.  The  methods 
used  for  teaching  children  might  here  be  employed,  but 
more  elaborate  and  designed  methods  can  be  used  with  the 
adult,  e.g, 

1.  Breathing  exercises,  especially  with  the  idea  of  making 

respiration  complete. 

2.  Blowing  exercises. 

3.  Whistling. 

4.  Vowel  sounding. 

S^guin  and  Rouma,  on  the  other  hand,  counsel  beginning 
exercises  with  consonants  in  stammerers  and  dyslalics. 

Re  tests  for  functional  deafness,  Ranjard  states  that  on 
account  of  the  complexity  of  Shell-shock  deafness,  exact 
diagnosis  needs  to  be  made.  Examination  of  the  hearing 
by  speech  aJone,  or  by  the  watch-tick,  yielded  poor  results; 
and  an  accurate  mathematical  acoumeter  {Sirene  d  voyelles, 
Marage)  Is  recommended.  See  especially  chapter  on  the 
functional  examination  of  audition  in  Bourgeois  and  Sour- 
dille's  War  Otitis  and  War  Deafness,  a  work  translated  and 
highly  recommended  by  the  English  otologist,  Dundas 
Grant. 


8lO  TREATMENT   AND    RESULTS 


Three  days'  skirmish  on  East  front :  Unconscious- 
ness, later  delirium,  still  later  (six  weeks)  stammer- 
ing, hysterical  stigmata :  Recovery  by  isolation  and 
reeducation. 


Case  579.     (BiNSWANGER,  July,  1915.) 

A  traveling  salesman  in  civil  life,  36,  as  a  non-commis- 
sioned officer  took  part  in  severe  fighting  in  the  East  shortly 
after  the  outbreak  of  the  war.  He  was  under  violent  shell 
fire  at  one  time  for  five  hours  at  a  stretch.  In  the  middle 
of  November,  after  a  skirmish  in  the  woods  which  had  lasted 
for  three  days,  he  was  found  unconscious.  According  to  his 
own  story,  he  was  awakened  from  this  unconsciousness  about 
a  week  later  in  a  hospital.  He  described  himself  as  quite 
unable  to  say  anything  about  what  had  gone  on  during  that 
week. 

The  medical  report  on  the  case  stated  that  he  arrived  at 
the  hospital,  November  18,  in  a  dormant  state  of  mind.  He 
had  appeared  markedly  excited  and  kept  incessantly  talking 
about  military  matters,  such  as  the  placing  of  machine  guns, 
the  occupation  of  the  edge  of  the  woods  by  his  company, 
addressing  the  nurse  as  "Captain,"  and  the  sister  as  "Mrs. 
Captain,"  making  as  it  were  an  official  report  to  them.  He 
showed  shyness,  and  always  an  extreme  excitement.  His 
hands  and  legs  were  in  constant  motion;  he  complained  of 
headaches  and  itching  finger-tips.  Sleep  could  be  achieved 
only  by  drugs.  This  mental  state  lasted  till  November  26, 
when  he  became  oriented.  Sleep  improved,  but  he  com- 
plained of  pains  in  the  back  of  the  head. 

Upon  transfer  to  a  convalescent  home,  December  5,  he 
was  still  occasionally  excited  and  sometimes  sleepless.  On 
December  30,  the  patient  began  to  stammer;  his  speech  had 
before  this  been  somewhat  difficult,  but  the  stammering  be- 
gan suddenly;  speech  was  indistinct  and  slow;  syllables 
failed  to  follow  one  another  at  like  intervals.  The  head- 
ache at  this  time  radiated  from  the  middle  of  the  top  of  the 
head  to  the  side  of  the  neck.     There  was  a  complaint  of 


TREATMENT   AND    RESULTS  8ll 

vibrating  pains  on  the  two  sides  of  the  vertebral  column,  and 
a  feeling  of  weakness  and  unsteadiness  in  walking.  The 
patient  would  sway  with  eyes  closed  and  turn  sidewise.  The 
heart  action  was  tumultuous,  the  pulse  irregular  and  uneven. 

The  patient  was  transferred  back  to  the  reserve  hospital 
on  January  2,  19 15,  whereupon  the  stammering  became  worse, 
sleep  restless,  and  arms  and  legs  subject  to  spasmodic  pains 
and  twitching.  On  January  25,  he  was  removed  to  the  Jena 
Hospital.  He  remarked  that  at  the  convalescent  home  he 
became  very  much  excited  at  the  Christmas  celebration  and 
had  to  cry,  whereupon  his  speech  became  more  and  more 
difficult;  he  could  not  find  the  beginnings  of  words  and  had 
to  stammer.  Upon  admission  he  also  complained  of  sharp 
pains  in  the  soles  of  the  feet  and  in  the  finger-tips. 

Neurologically,  there  was  marked  dermatographia,  the 
deep  reflexes  were  increased,  abdominal  reflexes  were  absent; 
there  were  points  of  pain  on  pressure  in  both  supra-orbital 
regions,  and  there  was  a  general  hypalgesia  with  the  excep- 
tion of  the  head,  the  lower  legs,  the  feet,  the  scrotum,  the 
penis  and  the  anal  region.  Pin-pricks  were  recognized  on 
the  right  side  only,  when  the  patient  was  tested  bilaterally. 
They  could  be  recognized  on  both  sides  when  the  patient  was 
examined  on  one  side  at  a  time.  There  was  a  static  tremor 
on  both  sides  (?).  He  could  move  his  arms,  but  in  dorsal 
decubitus  he  could  move  his  legs  only  jerkily  and  uncertainly. 
His  gait  was  waddling  with  dragging  of  toes. 

There  was  a  marked  photophobia.  The  palatal  and  swal- 
lowing reflexes  were  in  excess;  speech  was  hesitant  and 
stammering.  The  first  letters  of  words,  especially  initial 
consonants,  could  be  pronounced  with  difficulty,  explosively 
with  cheeks  blown  up,  after  several  attempts.  The  conso- 
nant would  be  repeated  several  times  before  the  vowel  could  be 
added.  The  patient's  name  was  Singer,  and  he  would  pro- 
nounce it:  S  ...  S  ...  S  ...  Si  ...  n  ...  n  .  .  .ger; 
the  last  syllable  {ger)  being  brought  out  with  a  strong  accen- 
tuation. The  whole  process  took  five  seconds.  The  word 
Flanelllatten  took  14  seconds.  It  seems  that  the  patient  had 
already  suffered  (in  1907)  from  nasal  catarrh  and  disturbance 
of  hearing  from  stoppage  of  the  Eustachian  tubes.     Another 


8l2  TREATMENT   AND   RESULTS 

attack  in  1908  had  been  accompanied  by  an  irritating  cough, 
and  there  seems  to  have  been  catarrh  on  the  right  in  191 3, 
as  well  as  cerumen  on  the  left  side. 

Treatment:  The  patient  was  isolated;  in  the  next  few 
days  there  was  improvement  in  the  headache.  The  patient 
complained  of  muscular  twitchings,  which  would  occur  sud- 
denly in  different  parts  of  the  body.  On  February  i  there 
was  a  subjective  feeling  of  happiness  since  all  pains  had  dis- 
appeared. 

The  patient  was  given  regular  exercises  in  speaking  and 
there  was  gradual  improvement  in  speech.  Body-weight  in- 
creased, regular  walks  were  taken,  and  the  patient  occupied 
himself  with  garden  work. 

By  June,  1915,  he  had  still  further  remarkably  improved, 
working  now  all  day  long,  partly  in  the  garden,  partly  in  the 
hospital  office.  Disturbance  of  speech  was  not  noticed  ex- 
cept for  hesitation  before  the  last  syllables  of  long  words  dur- 
ing comparatively  long  conversations.  All  trace  of  difficulty 
in  walking  had  disappeared.  In  this  patient  no  hereditary 
taint  could  be  proved.  He  appears  to  have  been  of  normal 
development,  serving  in  the  army  from  1901  to  1903.  In  his 
life  as  a  traveling  salesman,  there  was  frequently  catarrh  of 
the  throat,  and  in  1912  there  was  a  marked  swelling  of  the 
vocal  cords  with  extreme  hoarseness  and  inability  to  speak, 
which  condition  was  cured  after  local  treatment. 

Re  hysterical  speech  and  voice  disorders,  Binswanger  has 
found  them  amongst  the  most  obstinate  conditions,  often 
persisting  when  all  other  hysterical  phenomena  have  dropped 
away.  He  states  that  apparently  the  cure  of  some  of  these 
cases  must  be  postponed  until  the  end  of  the  war. 

Re  general  results  of  the  therapeutic  treatment  of  the  war 
hysterias,  Binswanger  states  that  he  has  been  able  to  send 
some  cases  back  to  the  front  that  have  successfully  stayed 
there.  He  has  had  failures,  however,  even  amongst  men 
who  have  had  no  maiwaise  volonte  and  have  themselves 
desired  to  be  sent  back  to  the  front. 

Gordon  Wilson  observed  250  cases  of  Shell-shock  at  the 
Ypres  salient  and  on  the  Somme.  Fifty  of  these  cases 
complained  of  deafness,  and  17  of  the  50  were  found  to  have 


TREATMENT   AND   RESULTS  813 

actual  nerve  deafness.  Wilson  treated  "fixed  idea"  cases 
by  hypnotism,  and  sometimes  by  cold  water  run  into  the 
ear.  He,  in  general,  divides  the  cases  in  to  {a)  cases  of 
nerve  deafness,  {b)  fixed  idea  cases,  and  (c)  malingerers. 

Marage  states  that  frequent  exposure  to  the  noise  of 
shells  for  long  periods  may  produce  a  permanent  deafness, 
as  has  long  been  known  in  naval  gun-makers  and  boiler- 
makers  in  peace  times.  He  advocates  obturators,  a  good 
form  being  plasticine  wrapped  in  gauze  moulded  to  the 
shape  of  the  Internal  meatus.  Celluloid  plugs,  sometimes 
used,  have  been  known  to  be  set  afire  by  the  flash  of  a  shell. 
Cerumen  sometimes  protects  against  deafness,  but  Mott 
speaks  of  the  driving  of  the  wax  Into  the  tympanum  as  a 
dangerous  effect  in  certain  shock  cases. 


8 14  TREATMENT   AND    RESULTS 


BURIAL    by    shell    explosion:    DEAFMUTISM. 
Treatment:  phonetic  reeducation. 


Case  580.     (LiEBAULT,  1916.) 

A  machine  gunner,  26,  was  buried  at  Rheims,  January  5, 
I9I5>  by  the  explosion  of  a  large  shell  bursting  over  the 
dugout.  He  was  unconscious  three  days  and  deafmute  on 
coming  to,  without  amnesia  but  with  a  feeling  of  constric- 
tion in  the  throat. 

After  fifteen  days  in  the  ambulance  he  was  sent  for  four 
months  to  the  Maritime  Hospital  at  Brest,  and  treated  by 
hypnotism.  Seven  or  eight  sittings  had  no  other  result  than 
to  fatigue  him.  There  were  then  three  months  of  conva- 
lescence. Returned  to  Vannes,  September  20,  191 6,  he  was 
put  into  the  auxiliaries.  As  he  could  not  work  much  he 
was  sent,  December,  191 5,  to  the  Hotel- Dieu  at  Nantes. 
Here  electric  vibratory  massage  was  given,  which  secured  a 
few  hoarse  sounds. 

Phonetic  reeducation  was  then  undertaken  at  Pres-a- 
goutriere,  May  10,  and  his  respiratory  capacity  increased 
from  170  the  first  week  to  250  and  300  the  following  wrecks. 
His  blowing  strength  was  raised  from  15  to  20  to  25  at  the 
same  time.  In  a  few  weeks  he  was  much  improved  and 
June  27  passed  on  to  his  auditory  reeducation.  The  res- 
piratory capacity  in  this  man  was  insufhcient.  He  could 
not  speak,  but  his  respiratory  movements  were  good  and  he 
learned  again  to  speak  in  a  voice  as  good  as  ever. 

According  to  Liebault,  it  is  a  general  principle  that,  if 
the  respiratory  capacity  is  increased,  the  voice  will  clear  or 
become  better;  but,  if  the  respiratory  capacity  remains 
stationary,  the  voice  will  not  improve.  It  is  the  same  with 
normal  persons.  A  subject  with  a  very  subnormal  respira- 
tory capacity  cannot  speak  loudly,  but,  if  his  respiratory 
capacity  approaches  normal,  he  can  speak  normally.  Ac- 
cording t&l  Liebault,  all  cases  of  this  sort  have  had  some 
respiratory  anomaly  and  each  case  must  be  systematically 
examined  with  the  aid  of  anthropometric /^tables,  including 


TREATMENT  AND  RESULTS  815 

weight,  height  and  chest  capacity.  The  vocal  disorder  is 
proportionate  to  the  degree  of  functioning  of  the  phonating 
apparatus  taken  as  a  whole.  It  is  not  merely  that  the 
larynx  should  be  examined,  but  the  motor  side  of  the  appa- 
ratus, the  respiratory  muscles,  the  resonating  apparatus,  the 
lips,  the  mouth,  the  nasal  fossae  and  the  pharynx. 

Re  curability  of  different  types  of  war  deafmute,  Roussy 
and  Boisseau  maintain  that  the  type  (a)  that  comes  ges- 
ticulating, pointing  to  the  ears,  and  desirous  of  writing,  is 
the  type  that  responds  most  rapidly  to  psychotherapy. 
There  are  two  other  types  less  responsive:  (&)  Is  an  apa- 
thetic type,  with  impassive  and  stupid  fades,  lies  Immobile 
in  bed,  or  sits  in  a  chair  in  mental  confusion;  type  {c)  shows 
a  fades  of  terror,  looks  haggard  and  anxious,  confused,  dis- 
oriented, and  possibly  delirious. 

Re  general  treatment  of  deaf  cases,  Zange  suggests  that 
emotion  should  not  be  aroused  by  intense  auditory  impres- 
sions, that  he  should  not  be  reminded  of  his  shock,  and 
should  be  kept  as  cheerful  as  possible.  Zange  states  that 
he  found  the  static  electric  current  of  service,  and  got  good 
results  In  hysterical  deafness  of  sudden  development  by 
applying  a  strong  faradic  current. 


8l6  TREATMENT   AND    RESULTS 


A  year's  service ;    leave :    Hysterical  aphonia  de- 
veloped at  home.     Respiratory  gymnastics. 


Case  581.     (Garel,  April,  1916.) 

A  soldier,  35,  went  on  leave  August,  1915.  Arriving  at  his 
farm,  he  had  a  violent  feeling  of  moral  perturbation  and  sud- 
denly lost  his  voice.  When  he  returned  from  leave  he 
seemed  stupid,  spoke  very  few  words  and  seemed  to  look 
about  in  a  vague  and  undecided  way.  He  was  several 
months  in  this  state  and  sent  January,  1916,  to  Saint- Luc. 

The  vocal  cords  were  there  found  of  a  normal  color  and 
without  paralysis.  "It  was,  therefore,"  remarks  Garel,  "a 
nervous  aphonia  susceptible  of  instantaneous  cure."  The 
patient  was  made  to  make  a  sound  in  the  lowest  tone  pos- 
sible. While  he  was  making  this  attempt,  sharp  pressure 
was  exerted  upon  the  lower  part  of  the  sternum,  to  provoke 
expiratory  reinforcement.  The  sound  emitted  was  loud,  to 
the  great  astonishment  of  the  patient,  who,  thus  aided  by 
suggestion,  shortly  began  to  talk  aloud. 

In  this  particular  patient  a  temporary  return  of  voice  was 
readily  obtained,  but  not  maintained.  Special  exercises  had 
to  be  instituted,  whereupon  the  patient  immediately  fell 
back  into  a  complete  aphonia.  He  was  then  made  to  scan 
words,  syllable  by  syllable,  executing  with  his  arms  classical 
movements  of  respiratory  gymnastics,  or  sometimes  with 
the  utterance  of  every  syllable  the  epigastrium  was  manually 
compressed  or  the  shoulders  suddenly  lowered.  The  patient 
could  now  read  a  book  in  a  jerky  manner,  and  after  a  few 
lines  he  could  read  without  his  shoulders  being  pressed. 

Another  plan  was  to  have  the  man  read  or  talk  while 
walking.  As  soon  as  he  was  stopped  and  accosted,  however, 
he  lost  his  voice  again.  Up  to  the  time  of  report  it  was 
impossible  to  secure  a  definite  return  of  voice,  as  the  patient 
was  not  willing  to  associate  words  with  peculiar  movements. 
It  might  make  him  ridiculous.  Accordingly,  the  nurses  were 
requested  not  to  fulfil  requests  unless  they  were  made  aloud. 
Recovery  was  to  be  hoped  for  from  this  measure. 


TJIEATMENT   AND    RESULTS  817 


Wounded:  Recurrent  stammering:   Reeducation. 


Case  582.  (MacMahon,  August,  191 7.) 

A  young  English  officer,  previously  cured  of  stammering 
while  a  boy,  fell  to  stammering  again  after  being  twice 
wounded.  The  impediment  was  of  the  laryngeal  type. 
When  spoken  to  he  was  often  quite  speechless.  In  Shell- 
shock  stammering,  the  chief  difficulty  according  to  Mac- 
Mahon is  in  the  production  of  voice  consonants  and  vowel 
sounds.     In  mild  cases  the  trouble  is  best  left  alone. 

This  officer  was  anxious  to  pass  into  the  regular  army  from 
the  reserve  to  which  he  was  attached.  The  stammering 
prevented  this.  He  was  treated  nine  months  and  improved 
rapidly.  He  passed  through  the  trying  ordeal  of  the  medical 
board  successfully  and  went  to  his  regiment. 

In  severe  cases  the  patient  is  taught  how  to  fill  his  lungs 
properly.  He  is  taught  to  acquire  an  inferior  lateral  costal 
expansion  in  inspiration.  During  expiration  the  abdominal 
muscles  are  trained  to  contract  slowly  and  strongly,  pressing 
the  diaphragm  upwards  and  drawing  the  lower  ribs  down- 
wards and  inwards.  This  steady  breathing  produces  a  sen- 
sation of  repose  in  the  stammerer.  He  is  not  to  raise  the 
upper  chest  and  not  to  tense  the  throat,  tongue  or  jaws. 

The  main  vowel  sounds  are  now  taught.  The  main  vowel 
sounds  are  00,  oh,  au,  ah,  a  and  ee.  They  combine  in  six  ways, 
oh  and  00  in  the  word  wound,  ah  and  ee  make  the  long  i, 
au  and  ee  in  boy,  oh  and  00  in  road,  a  and  ee  in  rain  and  fair, 
ee  and  00  in  new  and  you.  There  are  also  words  in  which 
no  main  vowel  or  compound  sounds  appear,  which  may  be 
placed  either  on  the  open  ah  position  or  the  closed  ee  position. 
Such  words  as  long,  abbot,  among,  which  are  on  the  position 
of  ah  and  such  words  as  it,  sister,  minister  which  are  in  the 
position  of  ee.  The  voice  consonants  are  b,  d,  g,  j,  1,  m,  n,  r, 
V,  w,  y,  z,  w,  w  being  00  sound  and  y  the  ee  sound.  The 
breathed  consonants  are  c,  f,  h,  k,  p,  q,  s,  t. 

The  treatment  of  stammering  intensified  by  Shell-shock 
is  more  difficult  than  that  of  Shell-shock  stammering  de  novo. 


8l8  TREATMENT   AND   RESULTS 


Wound  of  face:    Speech   disorder.    Recovery  by 
reeducation  in  two  months. 


Case  583.     (MacMahon,  August,  1917.) 

x'\n  officer  was  wounded  under  his  left  eye,  October  7,  1916. 
His  speech  was  affected  only  five  days  later  in  a  casualty 
clearing  station.  Observed  by  MacMahon,  November  5,  he 
was  found  to  speak  with  great  difficulty  and  became  ex- 
hausted after  a  few  words.  He  was  tensing  all  the  muscles 
in  attempting  to  speak.  Breathing  advice  was  given  and 
counsel  how  to  relax  in  the  abnormal  efforts. 

November  12,  the  officer,  who  was  at  Number  One  London 
General  Hospital,  began  to  speak  with  more  freedom.  "I 
am  getting  a  bit  better.  I  feel  I  must  keep  quiet,  and  it 
comes  after  a  bit.  I  think  far  quicker  than  I  speak."  He 
said  that  the  breathing  exercises  had  helped  him  most. 

November  15,  he  still  spoke  in  a  rather  staccato  way;  but 
the  words  did  not  check  as  they  had.  In  a  week  further 
there  had  been  so  much  improvement  that  he  was  discharged 
with  a  prognosis  of  complete  recovery. 

January,  191 7,  he  had  recovered. 


TREATMENT   AND   RESULTS  819 


Shell  wound  and  burial :  Camptocormia  (psycho- 
electric  treatment  successful  in  one  seance)  and 
lameness  (long  reeducative  treatment  successful). 


Case  584.     (RoussY  and  Lhermitte,  191 7.) 

At  a  Neuropsychiatric  Center,  September  2,  19 16,  arrived 
a  chasseur,  29,  showing  lameness  of  a  pseudocoxalgic  type  on 
the  left  side,  combined  with  an  anterior  camptocormia.  The 
whole  situation  had  lasted  a  year.  The  chasseur  had  been 
wounded  by  shell  explosion  on  the  left  side  and  was  buried 
on  July  29,  19 15.  He  lost  consciousness  and  had  respira- 
tory trouble  and  mutism.  His  arched  walk  and  lameness 
began  August  20,  1915. 

He  had  a  number  of  terms  in  hospital  and  six  months  at 
the  depot.  He  was  sent  back  to  the  front,  June  20,  1916, 
being  proposed  for  auxiliary  work.  There  was  some  mental 
weakness.  After  one  seance  of  electric  treatment,  the  im- 
proper attitude  of  the  trunk  was  corrected.  The  lameness, 
however,  persisted  and  required  long  daily  reeducation. 

The  patient  was  discharged  cured,  October  20,  19 16,  with- 
out lameness  or  camptocormia.  There  were  a  few  persis- 
tent lumbar  pains. 

Re  treatment  of  war  psychoneuroses,  Roussy  and  Lher- 
mitte recommend  rational  and  persuasive  psychotherapy 
after  the  manner  of  Dejerine,  Dubois,  Babinski,  and  others. 
Hypnosis,  they  sa}^  should  definitely  be  rejected.  Mental 
contagion  must  be  staved  off,  and  Roussy  and  Lhermitte 
believe  that  almost  all  cases  are  curable  and  should  be  sent 
back  as  competents. 

They  maintain  that  the  medical  officer  himself  plays  the 
leading  part.  Many  patients  are  "cured"  when  they  find 
"good  masters";  this  mastery  of  the  combined  confessor 
and  educator  Is  greatly  aided  by  prestige.  He  must  speak 
with  authority,  with  "Iron  in  the  velvet  glove";  but  with 
patience  and  persistence.  If  a  long  sitting  fails,  postpone 
work  on  the  pretext  of  resting  the  patient.  The  patient 
must  not  be  early  threatened  with  discipline.     Even  exag- 


820  TREATMENT   AND    RESULTS 

gerators  and  malingerers  must  be  talked  to  as  if  neuro- 
pathic. 

A  careful  medical  examination,  besides  correcting  false 
diagnoses  and  demonstrating  hystero-organic  associations,  will 
give  the  patient  confidence  in  his  physician. 

A  new  patient  is  more  easily  cured  than  an  old  one.  In 
general,  patients  should  be  treated  as  soon  as  possible  after 
the  shock.  Contractures  are  habitually  more  persistent 
than  paralysis;  tremors  and  tic  are  more  pertinacious  than 
deafmutism;  ante-bellum  psychoneuroses  are  less  easy  to 
treat  than  cases  developed  by  the  war  alone. 

The  neurological  centers  near  the  front,  with  their  disci- 
pline, inaccessibility  to  friends,  and  nearness  to  the  front, 
present  a  situation  which  yields  easier  and  quicker  cures 
than  the  interior;  but  after  the  two-years'  experience  which 
proved  this  fact,  according  to  Roussy  and  Lhermitte,  many 
cases  still  get  sent  back  into  the  interior  for  many  months, 
—  cases  that  ought  to  be  cured  near  the  front.  Cases  hav- 
ing convulsive  attacks  get  confinement  in  separate  rooms; 
chronic  neuropaths  are  kept  in  bed  on  a  milk  diet. 

The  general  features  of  the  treatment  of  psychoneuroses 
commended  by  Roussy  and  Lhermitte  are  summed  up  in 
what  they  call  the  psychoelectric  and  reeducative  method, 
divided  into  four  stages:  A  stage  (a)  of  persuasive  conver- 
sation; (b)  isolation;  (c)  faradization;  and  (d)  physical  and 
psychical  reeducation.  Roussy  and  Lhermitte  got  during 
six  months  in  one  of  the  army  neurological  centers,  98  to  99 
per  cent  of  recoveries.  Clovis  Vincent,  in  a  special  interior 
hospital  (see  for  Clovis  Vincent's  treatment,  a  summary 
under  Case  575).  Re  the  first  stage  of  persuasive  conversa- 
tions, Roussy  and  Lhermitte  discuss  on  the  day  of  admission 
the  general  nature  of  the  patient's  condition,  and  place  him 
in  the  atmosphere  of  cure,  in  contact  with  recovered  patients. 
The  conversation  takes  place  in  the  physician's  consulting 
room.  The  patient  is  gotten  to  promise  on  oath  that  he 
will  submit  to  any  methods  of  treatment.  Although  one 
may  pass  from  the  first  stage  to  the  third  or  electrical  stage, 
forthwith,  Roussy  and  Lhermitte  recommend  several  days  of 
isolation.     The  patient  is  placed  in  a  separate  room,   and 


TREATMENT   AND   RESULTS  821 

kept  in  bed  on  a  milk  diet.  This  isolation  treatment  of 
Weir  Mitchell  allows  reinforcement  of  the  suggestion  by 
talks  on  the  medical  rounds,  allows  the  patient,  perhaps,  to 
beg  for  the  electrical  treatment,  which  he  may  have  refused 
at  first,  and  lengthens  the  period  of  observation.  According 
to  Roussy  and  Lhermitte,  spontaneous  recovery  not  infre- 
quently takes  place  during  this  phase  of  isolation.  Lame- 
ness of  long  standing,  tremors,  and  deaf  mutism  disappear. 

The  third  stage  is  that  of  faradization,  executed  by  the 
physician  with  only  such  attendants  as  may  be  necessary 
to  support  the  patient.  At  first,  the  man  lies  nude  upon 
the  bed,  but  later  may  be  treated  while  sitting,  standing, 
walking,  or  running.  Feeble  currents  are  used  at  first; 
later  stronger  ones.  The  poles  are  applied  to  the  affected 
parts,  and  sometimes  to  especially  sensitive  parts  of  the 
skin,  such  as  the  ears,  neck,  lips,  soles,  perineum,  and  scro- 
tum. Energetic  treatment  by  the  rapid  method  is  indi- 
cated in  the  vast  majority  of  cases,  especially  at  the  front. 
If  a  case  is  seen  early,  the  rapid  energetic  treatment  almost 
always  cures  at  once.  The  success  of  the  method  depends 
upon  the  production  of  a  crisis,  which  ought  to  be  produced 
at  the  first  sitting.  Sometimes  this  sitting  has  to  be  con- 
tinued for  hours.  Some  patients  require  two  or  three  sit- 
tings; some,  still  more.  Instead  of  faradism,  a  cold  jet  of 
water,  or  even  painful  subcutaneous  injections  of  ether,  may 
be  used. 

The  fourth  stage  Is  that  of  physical  and  psychical  re- 
education, important  in  long-standing  cases.  The  various 
forms  of  physiotherapy  are  carried  out  by  special  assistants 
or  head  nurses,  accompanied  by  psychotherapy,  and  if  nec- 
essary by  electricity.  According  to  Roussy  and  Lhermitte, 
these  reeducative  methods  used  alone,  without  previous 
faradic  treatment,  are  not  successful.  Relapse  follows 
premature  transference  from  the  front  to  hospitals  in  the 
interior,  and  too  early  sick  leave. 


822  TREATMENT   AND    RESULTS 


Shell-shock  deafmutism.  Speech  recovered  by 
suggestion  and  reeducation;  hearing  by  reeduca- 
tion. 


Case  585.     (LiEBAULT,  October,  1916.) 

A  corporal,  20,  was  exposed  to  the  shock  of  an  aerial 
torpedo,  Januar>^  18,  1916,  at  Souchez.  The  torpedo  fell  a 
meter  away.  There  was  no  loss  of  consciousness,  but  the 
patient  was  agitated  for  several  hours,  not  knowing  what  he 
was,  doing.  Evacuated  to  hospital,  he  remained  several 
days  in  a  stupid  state.  He  was  completely  deaf  and  remem- 
bered poorly  what  had  happened.  He  made  every  effort  to 
speak,  but  could  not.  His  head  felt  on  fire.  He  could  not 
open  his  mouth  well  and  his  lower  jaw  was  almost  in  a  state 
of  contracture.  He  felt  that  his  tongue  could  not  move 
easily.  In  this  status  he  remained  until  February,  always 
trying  to  talk,  but  not  succeeding. 

He  then  arrived  at  Hotel- Dieu.  The  mouth  was  now 
opening  better  and  he  w^as  in  a  better  general  status,  though 
always  feeling  fatigued.  \^ibratory  massage  was  given  to 
the  laryngeal  region.  He  was  gradually  got  to  emit  a  few 
sounds  in  a  low  voice.  He  was  sent,  April  26,  to  Pres-a- 
goutriere.  He  was  now  somewhat  vocal,  but  at  times  would 
become  completely  aphonic  once  more.  The  voice  during 
the  first  few  weeks  of  treatment  became  better,  and  the 
respiratory  capacity  was  increased  from  450  the  first  week  to 
460  and  500  in  the  next  two  weeks. 

May  12,  he  suddenly  lost  his  voice  again  and  wanted  to 
commit  suicide.  However,  in  three  more  days  he  was  able 
to  speak  normally  again  and  has  had  no  relapse.  He  was 
then  put  under  auditory  reeducation  and  at  the  time  of 
report  his  hearing  had  slightly  improved. 

Liebault  remarks  that  during  the  time  when  the  patient 
could  not  speak  his  jaw  muscles  were  contracted  and  his 
tongue  could  not  mobilize  well.  He  could  think  words  but 
could  not  articulate  them.  It  was  accordingly  important  to 
cultivate  the  normal  functioning  of  these  muscles. 


TREATMENT  AND  RESULTS  823 


Gassing;  tracheitis;  crash  from  airplane;  un- 
consciousness: mutism;  stammering.  Reeduca- 
tion; hypnosis. 


Case  586.     (MacCurdy,  July,  191 7.) 

A  lieutenant  in  the  Royal  Flying  Corps,  23,  described  as 
"unusually  normal,"  a  successful  business  man,  athletic, 
socially  popular,  had  been  for  a  year  in  the  Infantry.  He 
was  caught  suddenly  in  a  gas  attack,  and,  though  he  re- 
covered after  a  few  days  in  bed,  had  a  severe  tracheitis  and 
laryngitis.  The  lieutenant  had  been  very  proud  of  his  voice 
and  its  carrying  power.  He  went  to  a  laryngologist  in  Lon- 
don, who  said  that  he  would  never  be  able  to  sing  again  —  a 
matter  of  some  worry. 

He  soon  became  an  expert  airman.  In  the  spring  of  191 7 
he  was  shot  at  by  antiaircraft  guns  in  a  trip  over  the  enemy's 
lines.  One  of  the  wings  was  hit  and  so  weakened  that  in 
landing  the  lieutenant  crashed  to  the  ground.  He  was  un- 
conscious for  three  hours  and  on  coming  to  tried  to  shout  to 
his  servant  in  the  distance,  who,  on  arrival,  found  the  lieu- 
tenant quite  unable  to  speak. 

According  to  MacCurdy,  there  was  here  a  conversion  hys- 
teria with  regression  to  the  tracheitis  that  followed  the  gas- 
sing. The  mutism  MacCurdy  regards  as  a  pathological  de- 
gree of  an  effort  of  protection  for  his  voice.  In  hospital 
three  weeks  later  he  learned  to  whisper  a  few  words,  though 
with  great  mental  effort.  He  regained  the  voiced  sounds  by 
coughing  and  then  saying  "ah."  Stammering  now  devel- 
oped. Not  more  than  one  or  two  words  could  be  said  at  a 
breath.  Training  to  say  two,  three,  four  and  then  five  letters 
in  one  expiration  yielded  improvement  in  the  stammering. 
Under  mild  hypnosis,  to  the  degree  merely  of  distraction, 
normal  speech  was  re-attained.  There  was  no  relapse. 
Singing  was  then'practiced  and  in  a  period  of  six  weeks  the 
singing  voice  was  virtually  as  good  as  it  ever  had  been. 


824  TREATMENT  AND  RESULTS 


Shell-shock :  Loss  of  consciousness,  possibly  hem- 
orrhage from  head :  Spontaneous  gradual  recovery 
from  anesthesias  in  three  months :  Recovery  from 
paralysis  by  reeducation  in  a  few  more  weeks. 


Case  587.     (BiNSWANGER,  July,  191 5.) 

A  German  youth  of  19  volunteered  at  the  outset  of  the 
war  as  a  motor  cycle  rider.  About  the  end  of  October,  he  was 
hurled  from  his  wheel  by  a  shell  which  struck  close  beside 
him  and  exploded,  knocking  his  back  against  a  pile  of  beams. 
He  lost  consciousness.     There  may  have  been  hemorrhage. 

He  came  to,  two  hours  later,  in  the  dressing  station,  hardly 
able  to  move  his  limbs.  Such  movements  as  he  could  make 
were  painful.  There  was  an  evident  contusion  of  the  back. 
He  had  a  fainting  fit  after  his  bath  in  the  field  hospital  and 
then  could  get  to  bed  only  with  support.  Severe  pains  in  the 
legs,  especially  in  the  knee. 

In  the  reser^'e  hospital,  there  was  a  second  similar  fainting 
spell,  followed  by  buzzing  in  the  head,  feelings  of  pressure  in 
the  chest  and  an  irregular  pulse;  all  of  which  phenomena 
disappeared  the  morning  after  the  fit. 

A  careful  examination  about  the  middle  of  November 
showed  the  persistence  of  a  severe  paresis  of  the  left  arm, 
and  a  less  marked  motor  weakness  of  the  right  arm.  Both 
legs  were  paretic,  and  there  were  no  spontaneous  movements 
of  the  leg.  This  paresis  of  the  legs  was  combined  with 
complete  anesthesia  and  analgesia.  Sensory  impairment 
was  found  only  in  the  right  arm  and  trunk,  and  there 
was  no  evidence  of  sensory  impairment  in  the  left  arm. 
Both  motor  and  sensory  disturbances  of  the  arm  disappeared 
rapidly. 

However,  at  the  beginning  of  December,  1914,  the  complete 
insensibility  of  the  lower  extremities  up  to  the  groin  still 
persisted.  The  anesthesia  then  began  to  retreat,  so  that  four 
days  later,  the  upper  limit  of  anesthesia  was  somewhat  below 
the  groin.  There  could  be  found  a  circumscribed  area 
of  anesthetic  skin  over  the  os  sacrum  up  as  far  as  the  second 


TREATMENT   AND   RESULTS  825 

vertebra  of  the  os  sacrum;    but  the  skin  around  this  area, 
as  well  as  over  each  tuber  ischii,  gave  normal  sensation. 

The  anesthesia  continued  to  retreat:  to  the  middle  of  the 
thigh  at  the  middle  of  December;  to  a  level  3  cm.  above  the 
knee-cap  at  the  end  of  December;  to  the  upper  end  of  the 
knee-cap  on  the  right  side  and  the  middle  of  the  left  knee- 
cap, January  i.  January  11,  the  anesthesia  had  retreated 
to  a  level  10  cm.  below  both  right  and  left  patella.  February 
8,  sensibility  in  the  legs  had  entirely  returned. 

While  the  anesthesia  was  pursuing  this  favorable  course, 
the  motor  symptoms  failed  to  improve  to  any  marked  extent, 
although  active  motion  of  the  legs  with  the  patient  in  dorsal 
decubitus  had  gradually  returned  to  a  limited  degree. 

The  diagnosis  upon  arrival  at  the  Jena  Nerve  Hospital 
was  "  rheumatism  of  the  left  side  of  the  body  and  dislocation 
of  the  spine." 

The  treatment  consisted  at  first  of  rest  in  bed  and  moist 
dressings  of  the  legs,  but  the  treatment  had  to  depend  greatly 
upon  the  diagnosis.  The  patient  complained  of  difficult 
micturition;  yet  there  were  no  other  positive  signs  of  or- 
ganic disease,  of  spine  or  cord. 

Hysteria  was  the  diagnosis  preferred  to  rheumatism,  de- 
spite the  fact  that  examination  at  the  Jena  Hospital  failed 
to  show  any  disorder  in  pain  or  tactile  sense. 

The  patient  was  a  rather  tall  man  of  slender  build,  with 
a  slightly  accentuated  second  pulmonic  sound,  decidedly 
increased  tendon  reflexes,  weak  plantar  reflexes,  and  many 
points  painful  on  pressure  in  various  parts  of  the  head,  over 
the  spine,  and  in  the  sciatic  regions.  The  vertebral  sensi- 
bility to  pressure  was  most  acute  in  the  region  of  the  third, 
fourth,  and  fifth  thoracic  vertebrae.  There  was  a  marked 
dermatographia.  There  was  no  other  sensory  disorder  and 
no  motor  disorder  of  the  arms,  though  the  left  hand-grasp 
was  weak.  All  passive  movements  could  be  successfully 
carried  out  with  the  legs.  Upon  bending  at  the  hip,  there 
were  subjective  feelings  of  tension  in  the  posterior  parts  of 
the  thighs.  In  active  motion  there  was  a  marked  limitation 
in  leg  movements,  which  appeared  to  be  executed  with  great 
difficulty  with   but   small   excursion   and  with  considerable 


826  TREATMENT   AND   RESULTS 

trembling.  The  knee-joint  could  be  flexed  only  when  the 
sole  of  the  foot  had  support.  The  lower  leg  could  not  be 
extended.  The  excursion  in  the  joints  of  the  feet  and  toes 
was  slight.  Muscular  strength  was  in  general  decreased. 
There  were  no  feelings  of  pain  in  muscular  action  but  merely 
feelings  of  great  effort.  Gait  was  slow,  shuffling,  unsteady, 
hesitating  and  only  possible  with  support.  Fatigue  set  in 
after  a  few  steps.  In  walking,  the  legs  could  hardly  be  bent 
at  the  knee.  The  soles  of  the  feet  dragged  on  the  ground. 
The  patient  was  unable  to  stand  upright,  and  when  placed 
upon  his  feet,  anxiously  and  stiffly  clung  to  some  support. 
Without  support,  he  fell  over  backwards.  When  supported 
he  could  move  his  legs  at  the  hip  and  lift  the  feet  from  their 
base  by  bending  the  knee-joints.  The  patient  could  not  sit 
in  a  chair  or  in  bed  except  with  support;  otherwise  he  would 
fall  to  the  right  side.  In  dorsal  decubitus  he  complained  of 
pain  in  the  loins. 

With  this  hysterical  picture,  treatment  of  a  psychothera- 
peutic nature  was  carried  out.  The  patient  was  given 
methodical  exercises  in  walking  and  standing,  during  which 
affirmative  suggestions  about  his  new  capacity  to  walk  and 
stand  were  given  with  monotonous  repetition. 

For  the  first  fortnight  he  walked  with  the  support  of  two 
nurses  for  a  half  hour  every  day.  He  was  very  industrious 
and  willing  to  execute  this  treatment;  and  later  began  to 
exercise  with  a  cane.  Two  days  later,  he  omitted  the  cane 
and  found  himself  able  to  walk  about  without  support.  He 
was  shortly  able  to  stand  without  swaying,  although  for 
some  time  the  walk  was  upon  a  rather  wide  base  and  some- 
what slow  and  suggestive  of  spastic  paresis. 

The  general  condition  of  this  patient  remained  good.  His 
appetite  and  sleep  were  good.  After  the  middle  of  March, 
191 5,  there  were  no  more  peculiarities  in  walking,  and  the 
patient  was  able  to  take  somewhat  long  walks  in  the  city 
and  vicinity.  He  applied  for  work  in  the  airship  division, 
for  which  he  already  possessed  some  experience. 

The  youth  appears  to  have  been  of  a  normal  mental  and 
bodily  development,  though  his  mother  is  said  to  have  been 
nervous  and  a  sister  died  of  convulsions  in  childhood. 


TREATMENT  AND   RESULTS  827 


Shell-shock  with  loss  of  consciousness:  Deaf- 
mutism,  rhythmic  head  movements,  anesthesia, 
asymmetrical  areflexia.  Recovery  by  suggestion 
with  faradism,  massage  and  reeducation. 


Case  588.     (Arinstein,  September,  191 6.) 

A  Russian  private,  30,  literate,  lost  consciousness  upon  the 
explosion  of  a  large  shell,  November  10,  191 5.  He  was 
brought  to  hospital,  November  14,  completely  deaf  and  dumb, 
and  with  his  head  rhythmically  swaying  sidewlse  60  to  70 
times  per  minute.  The  swaying  ceased  during  sleep.  The 
head  was  carried  inclined  to  the  right;  there  was  complaint 
of  headache.  The  left  leg,  the  trunk  and  the  hairy  part  of 
the  head  were  anesthetic.  The  knee-jerks  were  obtained 
with  difficulty,  the  Achilles  jerks  were  lively;  the  throat  and 
conjunctival  reflexes  were  absent;  the  abdominal  and  cre- 
masteric reflexes  were  lively.  The  right  plantar  reflex  was 
absent;  the  left  normal.  The  vision  of  the  right  eye  was 
impaired,  and  there  was  a  monocular  diplopia  of  this  eye. 
The  drum  membranes  were  pulled  In,  and  the  disorder  of 
hearing  was  explained  on  the  basis  of  labyrinthine  shock. 

After  a  seance  of  written  suggestion  with  faradism  to  neck 
and  small  palate  and  vibratory  massage  to  throat,  speech 
returned.  November  26,  the  patient  read  in  a  loud  voice  a 
written  phrase.  He  did  not  speak  again  Independently  until 
early  In  December,  when  he  read  aloud  written  matter. 
The  return  of  spontaneous  speech  was  gradual.  Hearing 
returned  December  5,  when  he  was  able  to  hear  in  the  right 
ear  by  means  of  a  tube.  In  the  sitting  posture  there  was  less 
swaying  of  the  head.  If  the  patient  lay  down,  rhythmic 
movements  of  the  head  became  stronger  and  more  rapid  (120). 


828  TREATMENT   AND   RESULTS 


Shell   explosion ;  unconsciousness :   Amnesia ;   pa- 
ralyses.    Reeducation. 


Case  589.     (Batten,  January,  1916.) 

A  corporal  in  the  Belgian  army  was  mobilized  when  the 
war  broke  out,  and  was  in  action  continuously  in  the  retreat 
from  Liege,  in  the  siege  of  Antwerp,  and  finally  on  the  Yser 
until  October  27,  1914,  when  the  explosion  of  large  shells 
rendered  him  unconscious.  He  recovered  consciousness  only 
in  hospital  at  Calais.  Though  he  was  able  to  see  and  hear 
well,  he  was  dazed  and  remembered  nothing  of  what  had 
happened.  In  fact,  he  did  not  understand  what  was  said  to 
him. 

In  a  week's  time,  his  memory  and  intelligence  returned, 
save  for  periodic  attacks  in  which  he  was  dazed.  From  the 
very  beginning  he  had  been  quite  unable  to  move  his  legs,  and 
at  first  the  arms  were  weak.  He  had  a  series  of  attacks  of 
\'iolent  struggling  in  November  and  December,  19 14,  which 
the  corporal  himself  called  fainting  attacks,  claiming  that 
he  did  not  move  his  legs  in  the  attacks  but  only  his  arms. 
In  fact,  he  claimed  that  he  could  move  neither  head,  body, 
nor  legs,  but  only  the  arms.  He  said,  "  Sometimes  I  try 
hard  and  set  my  teeth,  but  I  do  not  know  how  to  move  my 
head  and  my  legs;  I  try  but  they  do  not  move."  Sphincter 
control  was  maintained.  Although  he  could  see,  when  he 
attempted  to  read,  everything  went  black. 

He  was  finally  admitted  to  the  National  Hospital  for  the 
Paralyzed  and  Epileptic  on  July  8,  191 5,  on  the  service  of 
Major  Walshe.  He  was  thin  and  wasted.  He  was  firmly 
con\dnced,  according  to  the  notes  of  Major  Walshe,  that  he 
was  seriously  paralyzed.  He  said  he  could  not  lift  his  head; 
when  his  body  was  lifted,  his  head  fell  back,  or  rather  perhaps 
was  definitely  thrown  back,  lolling  about  alarmingly.  How- 
ever as  he  lay  in  bed  he  frequently  lifted  his  head  uncon- 
sciously and  placed  his  hands  under  it.  When  asked  to  lift 
his  head,  the  sternomastoids  were  strongly  contracted,  but 
at  the  same  time  the  neck  extensors  also,  so  that  the  head  was 


TREATMENT   AND    RESULTS  829 

stiffly  and  strongly  held  in  an  extended  position.  Despite 
the  patient's  statement  that  he  could  not  move  the  trunk 
muscles,  he  could  turn  over  readily  in  bed,  and  when  trying 
to  move  the  head  the  trunk  was  fixed  in  a  strong  opisthotonos, 
and  the  abdominal  walls  were  rigid.  When  requested  to 
move  his  legs,  he  made  no  movement  whatever,  though 
during  head  movements  the  legs  were  strongly  fixed  in  ex- 
tension. On  passive  movements,  there  was  no  active  mus- 
cular resistance.  There  was  an  indefinite  blunting  of  all 
kinds  of  sensations.     Reflexes  were  normal. 

Major  Walshe  worked  hard  with  the  patient,  inducing  him 
first  to  lift  his  head  from  the  pillow,  and  finally  to  move  the 
legs.  In  three  weeks'  time,  the  corporal  could  just  sit  up, 
and  at  the  end  of  another  month,  he  was  able  to  stand  in  the 
walking  machine.  At  the  end  of  a  third  month,  he  was 
walking  upon  crutches,  and  at  the  end  of  another,  he  could 
walk  upon  two  sticks  with  his  feet  wide  apart,  moving  as  if 
glued  to  the  floor.  To  quote  Batten,  "  The  corporal  will 
eventually  get  well  but  not,  I  think,  before  the  end  of  the 
war." 


Cosi  od'  IS  che  solava  la  lancia 

d'Achille  e  del  suo  padre  esser  cagione 
prima  di  trista  e  poi  di  buona  mancia. 

Thus  I  have  heard  that  the  lance  of  Achilles, 
and  of  his  father,  used  to  be  occasion 
first  of  sad  and  then  of  healing  gift. 

Inferno,  Canto  xxxi,  4-6, 


830 


E.   EPICRISIS* 
Terminology 

1.  Shell-shock,  a  lay  term,  usually  refers  to  the  medical 
entity  or  disease-group :  functional  neurosis,  or  more  briefly, 
neurosis. 

The  history  of  the  term  Shell-shock  will  repeat  that  of 
Railway  Spine  in  the  last  century;  the  term  will  fall  into 
disuse  when  the  cases  subsumed  thereunder  get  their  exact 
medical  diagnoses  —  which,  statistically  speaking,  will  prove 
to  be  as  a  rule  psychoneuroses,  either  hysteria  (pithiatism), 
neurasthenia  (nervous  exhaustion,  "  prostration"),  or  psychas- 
thenia  (obsessive  neurosis). 

2.  But  the  laity  cannot  be  got  to  use  the  term  Shell-shock 
in  this  exact  sense,  because  the  laity  cannot  make  exact 
diagnoses. 

In  the  post-bellum  and  reconstruction  period  the  physician 
will  need  to  guard  against  regarding  all  cases  called  Shell- 
shock  as  really  neuroses,  merely  on  the  ground  that  Shell- 
shock  is  probably  neurosis.  Laymen  will  in  the  reconstruction 
period  succumb  to  the  lure  of  the  lOO  per  cent  and  gossip  about 
cures  and  failures  in  the  same  loose  manner  that  is  but  too 
familiar  in  discussions  of  Lourdes,  Christian  Science,  the 
Emmanuel  Movement.  It  will  be  worth  while  to  preserve 
a  certain  generality  and  comprehensiveness  for  the  term 
Shell-shock,  which  will  stand  to  medicine  as  the  term  weeds 
stands  to  botany. 

3.  In  short,  keep  the  connotation  but  try  not  for  any 
denotation  of  this  lay  term  Shell-shock  in  the  lay  mind! 

The  dangerous  history  of  the  term  dementia  praecox  may 
be  recalled.     Neither  dementia  nor  praecox  is  an  exact  term 

*  Material  is  here  drawn  passim  from  the  compiler's  Shat- 
TUCK  Lecture  on  Shell-shock  and  After,  read  before  the 
Massachusetts  Medical  Society,  Boston,  June  18,  1918. 

8:,i 


832  EPICRISIS 

except  for  the  statistical  majority  of  cases  of  schizophrenia. 
Yet  does  not  the  layman  hearing  the  term  dementia  feel 
entitled  to  assume  that  a  victim  must  be  demented  or  become 
so? 

4.  The  term  Shell-shock  appears  to  be  a  perfect  term  for 
the  ordinary  man,  as  it  means  much  and  little,  connotes 
enormously  and  denotes  a  minimum  and  casts  the  lay  hearer 
back  upon  the  expert. 

But  confronted  by  the  term  Shell-shock,  the  ardent  social 
worker  or  the  ordinary  man  fails  to  get  any  incorrect  notion 
about  the  nature,  and  especially  about  the  prognosis,  of  the 
condition.  If  there  is  any  suggestion  of  prognosis,  it  is  the 
correct  suggestion  of  curability  possibly  conveyed  by  the 
suddenness  implied  in  the  term  shock;  but  I  defy  the  ordi- 
nary man  to  get  from  the  ordinary  term  Shell-shock  very  much 
that  denotes  anything  in  particular.  All  he  gets  is  an  enor- 
mous connotation.  This  connotation  may  run  back  for  the 
race  into  tree  stumps,  savages  brandishing  spears,  palatial 
decorations,  the  protrusion  of  animal  spirits,  the  Leyden  jar 
(sometimes  familiarly  known  as  the  "  shock  bottle"),  and  the 
aspen  shaking  of  the  man  in  fear  or  its  interior  equivalent. 
But  whether  the  slang  runs  back  so  far  or  no,  and  whether  the 
shell  is  a  shell  of  powder  or  a  shell  of  fear,  and  whether  the 
shock  is  of  solid  particles  or  in  a  moral  sense,  the  problem 
is  implicitly  laid  down  in  the  slang  (see  historical  discussion, 
Shattuck  Lecture). 

5.  The  terminological  difficulties  are  clarified  somewhat  by 
the  French  distinction  of  etats  commotionnels  and  etats 
emotionnels  in  the  Shell-shock  group. 

The  French  very  neatly  distinguish  what  they  term  etats 
commotiomiels  from  etats  emotiomiels.  They  think  of  the 
etats  commotionnels  or  commotional  states  much  as  we  think 
of  commotio  cerebri,  that  is,  of  a  physico-chemical  happening 
in  the  brain  of  an  essentially  curable  (or  reversible)  nature; 
that  is,  of  something  that  falls  short  of  being,  as  they  say, 
lesionnel,  namely,  as  bringing  about  a  structural  lesion.  That 
is,  they  distinguish  a  brain  with  a  visible  focal  lesion  from 
one  which  has  sustained  a  physical  jar  or  commotion,  and  they 
distinguish  the  effects  of  both  of  these  from  the  etats  emotion- 


EPICRISIS  833 

nels  or  emotional  effects  of  an  injury.  The  nomenclature  here 
brings  out  one  of  the  most  fundamental  difficulties  in  the 
whole  field  of  so-called  Shell-shock,  namely,  the  distinction 
between  structural  conditions,  microscopic  or  macroscopic, 
on  the  one  hand,  and  functional  conditions  of  a  psychopathic 
nature,  on  the  other.  The  commotion  would  affect  the  neu- 
rones themselves  in  some  perhaps  invisible  but  still  genuine 
physico-chemical  way,  whereas  the  emotion  would  affect 
these  neurones  merely  after  the  manner  of  the  normal  emo- 
tional life,  except  that  the  neurones  would  perhaps  deliver 
an  excessive  stream  of  impulses. 

6.  Terminology,  especially  in  the  matter  of  explanations 
to  laymen  (Americans  demand  monosyllabic  explanations  as 
a  preliminary  to  taking  suggestions!),  is  not  always  assisted 
to  clearness  by  physicians  on  account  of  the  old  ontological 
fallacy  that  Charcot  insisted  on. 

Would  that  the  medical  profession  understood  neuroses  at 
their  true  value!  Only  too  frequent  is  the  impression  on  the 
part  of  the  profession  that  imaginary  symptoms  are  by  the 
same  token  non-existent!  I  have  even  heard  a  physician  well- 
trained  in  somatic  lines  say  that  Shell-shock  did  not  exist  be- 
cause Shell-shock  was  nothing  but  neurosis,  and  neuroses  were 
characterized  by  imaginary  symptoms,  —  accordingly  neu- 
roses, being  imaginary,  do  not  exist!  All  of  which  reminds  us 
that  many  of  the  profession  were  entirely  skeptical  when 
Charcot  made  his  original  observations.  Some  men  here  in 
America  felt  that,  whereas  hysteria  might  occur  in  Paris,  it 
did  not  occur  to  any  extent  in  America.  The  Shell-shock 
data  of  this  war  will  abundantly  prove  to  the  profession  the 
existence  of  the  neuroses,  and  I  feel  that  physicians  will  have 
to  brush  up  their  ontology  to  the  extent  of  conceding  that 
a  symptom  may  he  in  a  sense  imaginary  and  yet  not  in  any  sense 
non-existent. 

7.  Babinski  points  out  a  case  of  hysterical  paralysis  of  a 
leg  which  led  the  patient  to  lean  so  heavily  upon  his  arm  as  to 
produce  an  organic  crutch  paralysis.  It  would  be  to  no 
point  to  argue  that  the  hysterical  paralysis  was  here  non- 
existent. Of  course  we  shall  have  to  meet  the  false  analogies 
drawn  from  methods  of  cure.     If  a  paralysis  can  be  cured  in  a 


834  EPiCRisis 

few  minutes  by  the  electric  brush,  or  by  hypnosis,  or  on  emer- 
gence from  chloroform,  or  by  some  other  modern  miracle, 
8.  Is  it  too  much  to  ask  the  profession  not  ever  to  say  that 
this  rapid  and  seemingly  miraculous  cure  was  brought  about 
because  the  disease  was  non-existent? 


Diagnostic  Delimitation  Problem 

9.  The  delimitation  problem,  taken  up  in  Section  A,  is  not 
identical  with  the  differentiation  problem,  taken  up  especially 
in  Section  C  but  passim  in  Sections  B  and  D ;  by  delimitation 
we  may  refer  to  the  process  of  localizing  the  diagnostic  battle 
through  exclusion  of  the  other  great  groups  of  mental  diseases 
that  d,  priori  ought  not  to  come  in  question,  but  do  come  in 
question  sometimes,  before  we  slice  down  to  the  question, 

10.  Is  there  or  is  there  not  evidence  of  destructive  lesion 
in  the  nervous  system  of  this  so-called  Shell-shocker?  Is 
this  man  a  victim  of  organic  or  of  functional  neurosis?  This 
latter  is  what  may  be  termed  the  differentiation  problem. 

Confining  ourselves  now  to  the  delimitation  problem, 
what  are  the  major  groups  of  mental  diseases  that  might 
come  in  question? 

I  shall  enumerate  these.  We  think  of  mental  diseases  as 
I,  syphilitic;  II,  hypophrenic  (that  is,  feeble-minded  in  some 
of  its  phases,  including  even  slight  degrees  of  subnormality 
not  entitled  to  be  called  feeble-minded  in  the  ordinary  sense) ; 
III,  epileptic;  IV,  alcoholic  (or  due  perhaps  to  some  drug  or 
poison) ;  V,  encephalopathic  (in  the  sense  of  some  focal  brain 
disease);  VI,  symptomatic  (in  the  sense  of  some  somatic 
disease);  VII,  senile  (or  presenile).  The  seven  groups  so  far 
enumerated,  I  believe,  the  general  profession  is  pretty  well 
equipped  to  consider,  at  least  roughly  to  diagnosticate  and 
to  handle  with  due  respect  to  the  interests  of  the  patient  and 
of  the  community.  I  am  bound  to  say  that  some  of  my  col- 
leagues would  not  go  so  far  as  to  the  competence  of  physi- 
cians in  general  in  these  fields,  and  one  is  aware  that  a  plenty 
of  mistakes  have  occurred  even  in  these  groups  through  the 
bad  judgment  of  practitioners.  Nevertheless,  I  hold  to  the 
conception  that  our  profession  is  reasonably  well  equipped  to 


EPICRISIS  835 

handle  these  greater  groups,  having  in  mind  all  the  while  the 
appropriate  temporary  calling-in  of  the  specialist.  But 
there  are  two  more  groups,  in  addition  to  these  seven,  in 
which  I  am  not  so  sure  that  the  general  profession  knows  as 
much  as  it  should.  I  refer  to  VIII,  the  schizophrenic  group, 
commonly  known  as  the  dementia  praecox  group;  and  IX, 
the  cyclothymic  group,  sometimes  termed  the  manic-de- 
pressive group.  It  is  the  victims  of  the  diseases  that  con- 
stitute these  latter  groups  that  ought  unconditionally  to  be 
excluded  with  few  exceptions  from  the  army;  and  it  is  the 
study  of  these  conditions  which  ought  to  be  carried  out  as  a 
part  of  every  man's  post-graduate  training,  not  merely  for  his 
work  on  draft  boards,  but  for  his  work  in  civilian  and  recon- 
struction practice.  There  is  another  group  of,  X,  psycho- 
neuroses,  with  which  the  profession  regards  itself  as  familiar, 
and  with  which  it  doubtless  is  familiar,  in  what  might  be 
called  blooming  examples  of  hysteria,  neurasthenia,  and  psy- 
chasthenia.  But  the  nub  of  the  situation  lies  in  the  fact  that 
the  diagnosis  of  instances  which  are  not  such  blooming  ex- 
amples is  difficult,  and  hence  it  was  that  I  qualified  my  state- 
ment as  to  the  competence  of  the  practitioner  in  this  tenth 
group.  It  is,  of  course,  the  tenth  group,  of  psychoneuroses, 
into  which  the  majority  of  the  Shell-shock  cases  fall. 

11.  Now  a  study  of  the  literature  of  the  belligerents  having 
Shell-shock  in  mind  as  its  special  topic  and  aim  proves  to  re- 
quire a  study  of  war  literature  in  all  of  these  groups.  There 
are  cases  of  so-called  Shell-shock  which  even  well-prepared 
medical  men  have  placed  in  the  neurosis  group,  when  they 
should  have  been  placed  in  one  or  other  of  the  groups  men- 
tioned. 

12.  In  short,  whereas  the  Shell-shock  delimitation  prob- 
lem deals  with  groups,  I,  II,  III,  IV,  VI,  VIII,  IX  and  (as 
our  compilation  shows)  especially  with  groups  I,  III  and  VI, 
on  the  other  hand  the  shell-shock  differentiation  problem 
deals  primarily  with  groups  V  and  X. 

To  clear  the  decks  for  action  re  the  differentiation  problem, 
let  us  dismiss  the  major  troubles  of  the  delimitation  problem 
as  shown  in  groups  I  (syphilitic),  III  (epileptic),  VI  (somatic) 
and  thereafter  very  briefly  refer  to  the  residue  of  the  delimi- 


836  EPICRISIS 

tation  problem.  For  convenience  of  reference,  a  few  out- 
standing remarks  concerning  the  general  relations  of  these 
divisions  to  war  and  peace  conditions  are  inserted  here.  We 
dealt  in  the  diagnostic  order  of  exclusion  with  19.J  cases, 
distributed  as  in  the  table  below  (bear  in  mind  that  the  method 
of  this  book  precludes  attaching  great  statistical  weight  to 
the  comparative  figures,  since  the  various  authors  published 
their  cases  for  their  special  rather  than  their  typical  interest) . 

I.  Syphilopsychoses 34 

II.  Hypophrenoses  (feeble-mindedness  and  imbecility) 18 

III.  Epileptoses 33 

VI.  Pharmacopsychoses  (alcohol;  morphine) 17 

V.  Encephalopsychoses  (focal  brain  lesion  cases) 15* 

VI.  Somatopsychoses 29 

VII.  Geriopsychoses  (senile  —  a  null  class) o 

VIII.  Schizophrenoses 16 

IX.  Cyclothymoses 7 

X  Psychoneuroses    12* 

XI.  Psychopathoses 15 

196 

13.  The  neuropsychiatric  side  of  syphilis  in  the  war 
is  presented  in  34  cases  (Cases  i  to  34).  The  syphilitic 
basis  of  sundry  military  difficulties,  quite  unsuspected  by  the 
laity  and  probably  not  too  well  understood  by  service  men,  is 
suggested  by  Case  i ,  a  case  of  desertion  by  a  French  officer  of 
high  rank.  Nor  is  Case  2,  in  which  visions  of  submarines 
proved  syphilitic,  without  its  warning.  Such  cases  point  only 
too  obvious  a  moral : 

14.  Neurosyphilitics  have  no  place  in  the  army  or  navy. 
Eight  cases  (Cases  3-10)  follow  in  which  the  aggravation  or 

acceleration  or  liberation  of  neurosyphilis  has  come  about 
under  the  conditions  of  war.  Some  of  these  cases  suggest 
the  gravity  of  the  problems  of  compensation,  allowance  and 
pension  that  may  arise.     We  might  ask, 

15.  Should  not  a  government  which  enlists  a  syphilitic 
pay  full  allowances  to  him  when  under  war  conditions  he 
becomes  a  neurosyphilitic? 

*  The  numbers  of  focal  brain  lesion  cases  and  of  psycho- 
neuroses  must  naturally  be  considered  in  relation  to  the  great 
groups  of  these  cases  in  Sections  B  and  C. 


EPICRISIS  837 

For  the  government  was  theoretically  able  to  learn  at  the 
start  (within  a  small  margin  of  error  by  means  of  the  serum 
test)  whether  the  man  was  syphilitic.  If  a  one-eyed  man  loses 
his  remaining  eye  in  an  industrial  accident  in  civil  life,  his 
damages  are  often  fixed  at  damages  for  total  blindness;  for 
the  industrial  firm  should  not  have  employed  a  one-eyed  man 
in  an  industry  dangerous  to  eyes.  The  principle  cannot  differ 
with  a  man  hired  in  a  spirochete-bearing  state:  The  com- 
pany has  hired  a  man  who  may  under  traumatic  conditions 
become  an  incompetent  neurosyphilitic,  and  should  pay 
damages  accordingly  when  the  aggravation  begins. 

16.  What  are  the  responsibilities  of  government  if  the 
neurosyphilis  is  due  to  a  syphilis  acquired  during  the  war? 

Often  such  infection  may  be  due  to  a  tragical  form  of 
"  negligence."  But,  as  pointed  out  in  a  work  on  Neuro- 
syphilis, 1917,  I  believe  that  any  form  of  licensing  system, 
official  or  virtual,  which  would  permit  the  purchase  of  syphilis 
in  or  near  military  zones,  abolishes  the  argument  of  "  negli- 
gence." A  man  acquiring  syphilis  under  the  connivance  of 
government  ought  to  stand  as  well  as  a  syphilitic  hired  by  the 
government,  when  it  shall  come  to  the  question  of  compen- 
sation for  incapacity.  Yet,  it  may  be  argued,  the  man 
might  have  remained  continent  after  all.  The  point  is  left 
to  the  mercy  of  jurists. 

17.  The  share  of  neurosyphilis  in  the  '^crimes"  and 
disciplinary  problems  of  the  army  is  intimated  in  three  cases 
(Cases  II  to  13). 

18.  The  latter  part  of  the  series  (Cases  14  to  31)  embraces 
problems  of  a  more  medical  nature,  touching  traumatic 
paresis  and  * 'Shell-shock  paresis."  Unusual,  these  cases 
may  be  readily  conceded  to  be;  but  their  infrequency  is  not 
such  as  to  put  them  out  of  the  field  of  consideration  in  the 
"  Shell-shock  "  group. 

Very  intriguing  to  the  diagnostician  would  be  the  cases  of 
pseudotabes  and  psetidoparesis  (Cases  23  and  26  of  Pitres  and 
Marchand),  were  such  cases  at  all  frequent. 

Case  28,  in  which  shell-shock  (the  physical  event)  ap- 
parently caused  recurrence  of  a  syphilitic  (!)  hemiplegia,  is 
particularly  instructive  and  might  better  belong  with  the 


838  EPICRISIS 

series  (under  Section  B:  Nature  and  Causes,  Cases  286-301) 
in  which  ante-bellum  weak  spots  were  picked  out  by  shell- 
shock  and  war  conditions.  But  Case  28  is  placed  here  for  its 
syphilitic  interest. 

Case  29  stands  out  as  a  warning  example  not  to  crowd  the 
hypothesis  and  try  to  make  syphilis  sponsor  for  everything, 
even  when  it  plainly  is  at  work. 

Cases  32-34  are  cases  in  which  syphilis  played  a  part, 
though  possibly  a  minor  part,  in  certain  peculiar  mental 
reactions. 

To  sum  up  the  part  played  by  syphilopsychoses  and  syphilo- 
neuroses  in  the  war,  we  find,  that 

19.  Syphilis  may  have  occasionally  a  serious  military 
effect,  as  in  the  case  of  desertion  by  a  French  officer  of  high 
rank. 

20.  Important  problems  of  pension,  retirement,  and  com- 
pensation are  brought  out,  and  as  no  previous  war  has  had 
the  benefit  of  the  Wassermann  reaction  and  other  exact  tests 
bearing  upon  the  nature,  progress,  and  curability  of  neuro- 
syphilis, we  may  hope  for  a  far  more  scientific  determination 
of  these  questions  by  review  boards  during  and  after  the  war. 

21.  We  find  a  few  instances  in  which  neurosyphilis  has 
played  a  part  in  the  discipline  of  troops.  According  to  one 
author  (Thibierge,  19 17),  syphilis  has  become  a  genuine  epi- 
demic among  French  soldiers  and  mobilized  munition  workers. 
In  Germany,  also,  it  may  be  remembered  that  Hecht  has 
claimed  that  no  less  than  an  equivalent  of  sixty  army  divisions 
has  been  temporarily  withdrawn  from  fighting  on  the  Teu- 
tonic side  for  venereal  diseases.  In  this  connection,  Neisser 
had  recommended  the  giving  of  salvarsan  and  mercury  in  the 
trenches.  According  to  Hecht,  the  appearance  of  syphilis 
should  be  a  signal  for  sending  a  man  to  the  front.  Hecht 
also  made  the  somewhat  bizarre  suggestion  that  special  com- 
panies of  syphllltlcs  should  be  formed,  for  convenience  of 
treatment,  on  the  firing  line. 

22.  A  more  solid  foundation  is  laid  for  the  theory  that 
general  paresis  may  be  evoked  by  trauma  —  a  conclusion 
already  fairly  well  established  by  civilian  cases,  notably  those 
of  industrial  accident. 


EPICRISIS  839 

23.  The  question  whether  shell-shock  (the  physical  event) 
can  produce  general  paresis  is  probably  to  be  settled  in  the 
affirmative,  for  it  may  always  prove  difficult  to  show  that  the 
physical  shell-shock  did  not  actually  produce  mechanical 
molar  lesions  of  the  brain,  permitting  the  rapid  advance  of 
spirochetes.  It  is  perhaps  easier  to  prove  that  shell  ex- 
plosion may  precipitate  neurosyphilis  in  the  form  of  tabes 
dorsalis  (take,  for  example,  Cases  21  and  22).  The  cases 
of  most  importance  in  the  question  of  traumatic  neurosyphilis 
and  traumatic  paresis  are  cases  20,  21,  22,  24  and  25, 

24.  The  picking  out  of  preexistent  weak  spots  by  Shell- 
shock  is  given  clear  Illustration,  as  in  the  case  of  Shell-shock 
recurrence  of  an  old  syphilitic  hemiplegia  (Case  28).  Only 
on  such  a  basis  could  the  syphilitic  ocular  palsy  of  Case  19 
be  satisfactorily  explained. 

25.  The  coexistence  of  functional  phenomena  with  or- 
ganic syphilitic  phenomena  is  demonstrated  by  Cases  29  and 
30;   perhaps  also  in  Case  16. 

26.  It  must  be  said  that  presumably  there  will  be,  unless 
our  authorities  are  more  successful  than  in  the  past,  a  con- 
sidera,ble  increase  in  venereal  disease  as  the  result  of  army  life 
in  wartime.  There  will  be  a  certain  number  of  cases  of 
neurosyphilis  a  number  of  years  after  discharge  from  the 
army  caused  by  infection  acquired  during  service.  (Ger- 
many is  said  to  have  got  its  crop  of  neurosyphilis  after  the 
War  of  1870,  in  the  early  eighties  of  the  last  century.)  The 
names  of  all  soldiers  acquiring  syphilis  and  not  considered 
cured  at  the  time  of  discharge  should,  under  ideal  conditions, 
be  given  to  health  organizations  in  their  home  states  so  that 
they  may  be  accorded  proper  care  and  treatment. 

27.  Shell-shock  and  epilepsy.  The  authorities  have  been 
somewhat  surprised  by  the  number  of  epileptics  that  have 
gotten  by  the  draft  boards.  The  statistics  are  not  yet  ripe, 
but  certainly  the  enlistment  of  an  epileptic  is  not  a  rarity. 
There  are  some  singular  instances  in  the  war  literature  show- 
ing how  hard  it  sometimes  is  to  bring  out  epilepsy.  There  is 
the  English  case,  for  example,  of  a  man,  an  epileptic's  son, 
who  had  him.self  been  epileptic  from  11-18,  who  entered  the 
Expeditionary   Force   at   the   outbreak  of  hostilities,   went 


840  EPICRISIS 

through  the  retreat  from  Mons  and  through  two  years  of 
active  warfare  without  having  a  single  epileptic  convulsion. 
In  fact,  in  September,  191 6,  he  was  put  in  charge  of  eight  men 
on  guard  duty.  Apparently  the  new  responsibilities  worried 
him,  and  two  months  later  he  had  become  epileptic  to  the 
extent  of  petit  mal. 

Another  man  who  had  never  been  epileptic  (though  his 
sisters  had  been)  was  wounded  four  times,  was  never  worried 
by  shell  fire,  got  somewhat  depressed  after  the  death  of  his 
father  and  five  brothers  in  the  service,  but  did  not  become 
epileptic  until  fina  ly  he  was  blown  up  and  buried  three 
times  in  one  day,  and  it  was  a  whole  month  later  when  he 
became  epileptic,  although  treatment  by  rest  and  bromides 
apparently  resolved  the  affair. 

Other  cases  seem  to  show  that  war  experiences  can  bring 
out  epilepsy,  although  n  most  instances  it  would  appear  that 
there  was  an  epileptic  or  otherwise  neuropathic  heredity  in 
these  cases. 

28.  There  is  one  author,  Ballard,  who  has  actually  pro- 
pounded a  theory  of  Shell-shock  as  epileptic,  pointing  out 
the  occurrence  of  epilepsy  long  after  the  early  symptoms  of 
Shell-shock  have  disappeared.*     There  does  not  appear  to 

*  In  one  instance,  fugue  and  other  minor  symptoms  were 
later  replaced  by  epilepsy;  in  another,  an  epileptic  confusion 
developed  eight  months  after  an  explosion,  and  in  a  third,  a 
case  of  mine  explosion,  stammering  resolved  into  mutism 
and  mutism  finally  into  epilepsy.  Of  course  there  is  a  so- 
called  general  resemblance  among  all  forms  of  hyperkinesis 
or  irritative  discharge  of  the  nervous  system.  If  we  term 
epileptic  all  the  things  that  various  authors  have  termed  epi- 
Icptoid,  we  may  be  doing  nothing  more  than  to  say  that  we 
believe  these  cases  all  subject  to  epileptic  hyperkinesis. 
In  that  direction,  of  course,  it  has  long  been  said  that  dipso- 
mania was  really  a  form  of  epilepsy.  Whether  Shell-shock  is 
ordinarily  subject  to  recurrence  in  such  wise  as  to  imitate 
the  recurrence  of  attacks  of  dipsomania,  of  manic-depressive 
psychosis  or  of  epilepsy,  is,  to  say  the  least,  doubtful  at  this 
time. 


EPICRISIS  841 

have  been  any  increase  in  epileptics  as  the  result  of  the  war, 
either  from  the  standpoint  of  Shell-shock  or  from  the  stand- 
point of  brain  injury,  so  far  as  the  records  of  the  National 
Hospital  for  the  Paralyzed  and  Epileptic  in  London  are  able 
to  show. 

29.  As  in  all  other  instances  of  mental  or  nervous  disease, 
when  an  epileptic  returns  from  the  war,  whether  or  no  he 
was  potentially  or  actually  an  epileptic  before  the  war,  his 
relatives  are  bound  to  term  him  a  case  of  Shell-shock.  I 
am  familiar  with  a  case  in  a  hospital  in  a  certain  Atlantic  port, 
a  case  of  pronounced  and  obvious  epilepsy.  In  the  wards  he 
is  treated  as  the  hero  of  every  occasion.  Not  only  the  nurses 
and  attendants,  but  the  other  patients  and  often  the  physi- 
cians can  hardly  resist  thinking  of  him  as  somehow  a  case  of 
Shell-shock.  It  is  a  comment  upon  the  status  of  mental 
hygiene  in  general  that  this  self-same  epileptic,  had  there  been 
no  war,  would  have  been,  as  it  were,  a  common  or  garden 
epileptic,  mute  and  inglorious  on  some  sunny  hillside. 

30.  In  passing  I  may  note  how  many  instances  in  the 
medicolegal  part  of  the  war  literature  there  are  of  epileptics 
who  come  up  for  courtmartial  or  for  medical  examination 
pending  courtmartial.  We  may  suspect  that  many  a  case 
of  epileptic  fugue  has  been  regarded  as  a  case  of  desertion. 
There  is  the  case  of  an  epileptic  who  left  camp  one  morning 
and  got  drunk.  Investigation  showed  that  he  left  camp 
before  anything  epileptoid  had  happened.  He  developed  in 
his  drunkenness  a  pretty  clearly  epileptic  crisis  with  great 
violence,  for  which  he  had  a  complete  loss  of  memory.  The 
French  Council  condemned  him  to  five  years  of  labor,  not 
admitting  in  this  instance  that  responsibility  was  diminished 
by  reason  of  the  man's  being  epileptic.  In  short,  from  the 
military  point  of  view,  he  should,  so  to  say,  have  known 
enough  not  to  have  gotten  drunk,  and  so  have  avoided  get- 
ting his  epileptic  crisis.  Of  course  the  decision  was  here 
very  close,  and  a  like  decision  would  not  always  be  rendered. 
To  add  to  the  complication  of  this  particular  case,  the  very 
first  epileptoid  crisis  which  caused  it  to  be  known  that  the 
man  fell  into  the  epileptic  group  was  due  to  Shell-shock,  or 
at  least  developed  immediately  after  the  bursting  of  a  shell 


842  EPICRISIS 

nearby.     On  the  whole,  however,  the  relation  between  epi- 
lepsy and  Shell-shock  is  not  a  close  one. 

31.  The  question  of  epilepsy  in  the  war  is  considered 
in  a  series  of  33  cases  (Cases  53-85).  The  considerations 
range  from  banal  cases  developing  quite  incidentally,  up 
to  cases  regarded  by  one  author  (Ballard)  as  illustrating 
a  theory  of  Shell-shock  as  epileptic  (Cases  82-84).  First 
are  considered  two  cases  actually  syphilitic.  In  the  first 
(Case  53),  the  diagnosis  had  to  be  revised  from  epilepsy 
to  neurosyphilis  (the  convulsions  of  this  neurosyphilitic  were 
brought  out  by  alcohol,  and  the  reporter,  Hewat,  remarks 
that  the  serum  of  any  patient  developing  epileptiform  seizures 
between  35  and  50  years  of  age  should  be  subject  to  test). 
In  Case  54,  the  soldier  got  his  syphilis  in  wartime  and  the 
syphilis  acted  to  bring  out  an  epilepsy  with  which  the  patient 
was  hereditarily  tainted  (epilepsy  syphilogenic,  i.e.,  reactive 
to  syphilis). 

Case  55  might  perhaps  better  have  been  considered  in 
the  group  of  hypophrenoses,  as  he  was  epileptic  and  imbecile. 
He  was  at  first  condemned  by  court  martial  to  five  years' 
imprisonment  for  leaving  his  post  in  the  presence  of  the 
enemy. 

Another  mixed  case  is  Case  57,  in  which  another  feeble- 
minded subject  showed  seizures  of  a  psychogenic  nature, 
which  he  was  able  eventually  to  stop  by  clenching  his  teeth. 

Seven  cases  (Cases  58-64)  are  cases  of  a  disciplinary  nature, 
amongst  which  attention  may  be  called  to  Case  62,  the 
"  specialist  in  escapes."  The  medicolegal  questions  of  re- 
sponsibility in  the  drunken  epileptic  (Case  58)  are  particularly 
perplexing. 

32.  Case  64  is  one  of  epilepsy  following  antityphoid  in- 
oculation one-half  hour.  There  were  five  attacks  during  a 
fortnight  and  then  no  others.  The  antityphoid  inoculation 
came  eight  weeks  after  a  shell  wound  of  the  thigh,  which 
had  not  serv^ed  to  bring  out  the  epilepsy  in  this  patient. 
BonhoefTer  had  three  other  instances  of  the  sort:  one  in  a 
severely  tainted  subject,  and  the  others  in  alcoholics. 

33.  The  next  group  of  cases,  66-77,  yields  a  series  of  the 
most  interesting  medical  problems,  some  of  which  scarcely 


EPICRISIS  843 

belong  in  an  account  of  psychoses  incidental  in  the  war. 
Case  66  is  one  with  recovery  from  Jacksonian  seizures  after 
decompression  of  the  upper  Rolandic  region,  which  was  edem- 
atous following  an  (apparently  very  slight)  scalp  wound  and 
shell-shock. 

34.  The  cure  by  studied  neglect  (in  Case  67)  is  one  of 
hystero-epileptic  convulsions  occurring  in  series.  Case  68 
demonstrates  the  superposition  of  hysterica  phenomena  over 
a  genuine  epilepsy,  a  case  therefore  with  two  diagnoses:  not 
hystero-epilepsy,  but  epilepsy  and  hysteria, 

35.  The  theoretical  implications  of  Case  69  are  striking: 
The  case  was  one  of  musculo-cutaneous  neuritis  (gross  en- 
largement), in  association  with  which  Brown-Sequard's 
epilepsy  developed,  waxing  and  waning  with  the  disease  of  the 
nerve.  Another  case  of  possible  reactive  epilepsy  is  Case  70, 
and  a  case  of  epilepsia  tarda  brings  up  the  same  Issue  (Case 
71).  Cases  72-74  are  cases  with  strong  psychogenic  compo- 
nents, of  which  Case  74  is  particularly  instructive  on  account 
of  the  gradual  building  up  of  a  remarkable  visual  aura  of  an 
approaching  fire- wheel,  this  aura  developing  after  scotoma 
from  looking  at  the  sun.  Cases  75  and  76  are  cases  of  some- 
what doubtful  epilepsy,  one  of  fugue  and  the  other  of  a  soli- 
tary epileptic  episode  following  38  artillery  battles  in  two 
months. 

36.  Friedmann  discusses  narcoleptic  seizures,  regarded  as 
due  to  the  brain  fag  of  trench  life  (Case  77).  Sham  fits  and 
epileptoid  attacks  controllable  by  will  appear  in  Cases  78  and 
79  respectively.  Case  80  is  a  striking  case  of  a  man  with 
epileptic  taint,  which  two  years'  service,  four  wounds,  the 
death  of  a  father  and  five  brothers,  and  eventually  Shell- 
shock  and  burial  thrice  in  one  day,  served  at  last  to  bring  out. 

37.  Shell-shock  and  bodily  disease.  In  civilian  psycho- 
pathic hospital  practice,  if  a  case  is  not  syphilitic,  not  feeble- 
minded, not  epileptic,  not  alcoholic,  and  without  signs  of 
intracranial  pressure  or  disorder  of  reflexes,  then  we,  as  special- 
ists, must  consider  whether  the  disease  in  question  is  not  due 
to  some  form  of  bodily  disorder  outside  the  nervous  system; 
for  example,  we  think  in  practice  of  Infectious  psychoses,  of 
exhaustive  states  such  as  the  puerperium,  of  toxic  states 


844  EPICRISIS 

such  as  may  be  found  in  cardiorenal  cases,  and  of  glandular 
phenomena  such  as  we  are  familiar  with  in  the  thyroid  dis- 
orders. 

Under  the  war  conditions,  it  might  be  thought  that  these 
somatic  disorders  yielding  the  so-called  symptomatic  mental 
diseases  would  be  frequently  found. 

Aside  from  these  rarities  in  puzzling  diagnosis,  we  find  more 
commonly  in  the  literature  evidence  of 

38.  The  soldier's  heart,  the  so-called  "D.A.H.,"  or  dis- 
ordered action  of  the  heart,  of  the  English  army  reports. 
This  soldier's  heart  is  sometimes  associated  with  hyperthy- 
roidism, and  sometimes  hyperthyroidism  is  found  alone, 
with  symptoms  suggesting  those  of  a  sort  of  diffuse  Shell- 
shock. 

One  author  claims  rapid  cures  of  hyperthyroidism  by  the 
relatively  simple  process  of  hypnosis.  Perhaps  this  is  not 
too  unlikely  in  view  of  the  '■  still  obscure  relations  between 
mind  and  hormones.  A  little  more  surprising,  perhaps,  is  the 
assertion  met  with  that  psoriasis  is  sometimes  a  Shell-shock 
phenomenon. 

The  literature  clearly  shows,  however,  that,  as  in  most 
special  problems,  the  internist  is  still  in  demand.  I  recall 
how  one  internist  was  misled  on  the  witness  stand  into  stating 
that  he  was  a  "  general  specialist."  This  is  what  we  would 
all  need  to  be,  were  we  to  solve  the  problems  of  Shell-shock 
in  the  time  allotted  to  us  by  the  war. 

39.  Following  are  special  cases  to  show  how  near  the 
somatic  ("  symptomatic")  may  be  to  Shell-shock. 

The  somatic  group  of  psychoses,  sometimes  termed  symp- 
tomatic, is  illustrated  in  29  cases  (Cases  1 18-146),  and  com- 
prises cases  ranging  all  the  way  from  rabic  phenomena  to 
those  of  hyperthyroidism.  Possibly  the  first  two  cases 
(Cases  118  and  119)  might  better  be  placed  among  the  en- 
cephalopsychoses.  Case  118,  one  of  rabies,  was  that  of  a 
farmer  without  history  of  having  been  bitten  by  a  dog,  who 
eventually  came  to  autopsy  and  received  the  Pasteur  In- 
stitute diagnosis  of  rabies.  A  diagnosis  of  angina  was  at 
first  made.  When  the  symptoms  became  more  serious  and 
masseter  spasm  developed,  a  question  of  tetanus  arose.     Later 


EPICRISIS  845 

the  diagnosis  of  meningitis  was  suggested.  At  this  point,  the 
symptoms  became  predominantly  psychotic. 

Case  119  was  one  of  seven  cases  reported  by  Lumlere  and 
Astier,  In  which  deUrium  and  hallucinations  appeared  as  a 
complication  of  tetanus.  The  case  in  question  had  been 
given  anti-tetanic  serum.  (Another  case  showed  Identical 
symptoms  without  having  been  given  anti-tetanic  serum.) 

That  a  local  tetanus  could  be  mistaken  for  hysteria  might 
seem  a  priori  unlikely,  but  Cases  120  and  121  Indicate  as 
much;  and  Case  121  is  Interesting  on  account  of  the  officer's 
own  description  of  his  local  tetanus  and  Its  treatment.  A 
psychosis  apparently  related  with  dysentery  occurred  In  Case 
122.  Hysteria  followed  typhoid  fever  In  Case  123.  An- 
other form  of  typhoid  fever  complication  is  perhaps  shown 
in  Case  124,  wherein  the  diagnostic  question  lay  between 
dementia  praecox  and  a  post-typhoid  encephalitis. 

Paratyphoid  fever  has  diagnostic  complications,  as  shown 
in  Cases  125  and  126,  wherein  the  mental  symptoms  out- 
lasted the  fever  (Case  125),  and  psychopathic  taint  was 
brought  out  (Case  126). 

Diphtheria  was  also  represented  in  the  matter  of  nervous 
and  mental  symptoms  in  Cases  127  and  128.  In  Case  127 
the  nervous  symptoms  appeared  eight  days  after  evacuation 
for  diphtheria.  There  were  a  few  sensory  symptoms  (hyp- 
algesia,  hypoacusia,  and  peculiar  bone  sensations)  in  this 
subject.  The  phenomenon  In  Case  128  was  apparently  one 
of  hysterical  paraparesis;  nor  does  It  appear  In  this  case  that 
the  hysterical  paralysis  was  preceded  by  polyneuritis. 

Malarial  effects  are  present  In  three  cases  (Cases  129-13 1), 
of  which  Case  129  showed  an  amnesia,  Case  130  a  Korsakow 
syndrome,  and  Case  131  anterior  horn  symptoms.  Case 
132  exemplifies  15  instances  of  acroparesthetic  disorders  In 
so-called  trench  foot.  This  case,  like  several  others.  Is  in- 
serted In  this  group,  not  because  the  symptoms  are  psy- 
chotic, but  because  they  might  cause  diagnostic  difficulty  as 
against  hysterical  phenomena. 

Case  133  Is  an  autopsled  case  of  bronchopneumonia  follow- 
ing bullet  Injury  of  the  spine.  Microscopic  examination  of 
the  spinal  cord  showed  small  cavities  In  the  first  and  fourth 


8-[6  EPICRISIS 

dorsal  segments.  This  myelomalacia  was  doubtless  related 
with  the  bullet  injury  of  the  spine,  although  the  spinal  cord 
was  not  itself  directly  touched  by  the  bullet.  Case  134  might 
be  regarded  perhaps  as  one  of  Shell-shock  and  should  be 
considered  in  relation  with  the  cases  at  the  head  of  Section  B 
(Cases  197-209).  The  case  might  be  regarded  as  functional, 
except  for  a  decubitus  that  developed.  Despite  this  decubitus, 
there  was  recovery.  The  case  is  placed  in  the  somatic  group 
on  account  of  pulmonary  phenomena  which  it  seemed  well  to 
relate  with  those  of  Case  133.  Compare  also  Case  136,  in 
which  reflex  phenomena  are  associated  with  a  bullet  wound 
of  the  pleura.  Case  135  is  a  many-sided  case,  with  ante- 
bellum hysteria  and  certain  Shell-shock  phenomena.  While 
under  observation,  the  patient  caught  typhoid  fever  and  then 
developed  neuritis.  This  neuritis  was  very  probably  not 
post-typhoidal  so  much  as  hysterical.  Accordingly,  the  case 
should  be  considered  in  connection  with  the  ante-bellum  weak 
spot  series,  Section  B  (Cases  286-301).  There  was  in  this 
case  a  cure  by  reeducation. 

The  reflex  hemiplegia  with  double  ulnar  syndrome  in 
Case  136  seemed  to  have  followed  a  bullet  wound  of  the  pleura. 
According  to  the  authors,  Phocas  and  Gutmann,  there  is 
considerable  literature  upon  nerve  complications  of  pleura 
trauma,  including  syncope,  epilepsy,  and  (more  rarely)  hemi- 
plegia. 

Heart  cases  are  illustrated  by  Cases  137-139:  the  first  one 
of  hysterical  tachypnoea,  and  the  others  of  the  so-called 
soldiers'  heart. 

Diabetes  mellitus  seems  to  have  followed  war  strain  and 
shell  wound  in  Case  140. 

It  is  doubtful  whether  shell-shock  and  burial  had  anything 
to  do  with  the  appearance  ten  days  later  of  lipomata,  which 
proved  to  be  the  initial  phenomenon  in  a  pronounced  Der- 
cum's  disease.  (Case  141). 

Hyperthyroidism  is  illustrated  in  four  cases  (Cases  142-144). 
The  first  (Case  142)  appears  to  have  been  cured  by  inducing 
deep  somnambulism  (Tombleson  claims  cures  by  suggestion  in 
eight  cases  of  hyperthyroidism).  Neurasthenia  or  question- 
able Graves'  disease  (Case  145)  followed  Shell-shock.     That 


EPICRISIS  847 

of  Case  144  followed  10  months'  service,  at  times  under 
protracted  shell  fire.  A  forme  fruste  of  Graves'  disease  is 
shown  in  Case  145,  in  which  the  phenomena  followed  gassing 
and  shelling. 

A  somewhat  curious  somatic  complication  In  a  case  of 
Shell-shock  hysteria  was  the  finding  of  a  needle  in  the  left 
upper  arm,  which  was  then  extracted.  (Case  146). 

The  Nature  of  War  Neuroses 

40.  Regarding  our  rough  delimitation  of  the  Shell-shock 
group  as  well  in  hand,  having  put  upon  one  side  three  of  the 
most  disturbing  groups  (save  one)  in  our  process  of  demar- 
cation, we  must  proceed  to  the  Shell-shock  material  itself ; 
a  material  now  definable  as  assuredly  non-s3'^philitic,  non- 
epileptic,  non-somatic,*  as  beyond  question  without  narrow 
relations  with  feeble-mindedness,  alcohol  and  drug  states, 
schizophrenia  and  cyclothymia,  and  as  probably  of  the  general 
nature  of  the  psychoneuroses. 

Note  that  in  this  epicrisis  I  have  designedly  not  followed 
the  order  of  presentation  of  the  text  materials.  The  process 
of  diagnosis  per  exclusionem  in  ordine  which  I  find  most 
serviceable  in  civilian  psychopathic  hospital  practice  is  the 
elimination  of  possibilities  in  the  order  presented  in  Chart  I 
or  in  Paragraph  10  of  this  epicrisis.  Because  this  book  will 
find  its  greatest  use  in  peace  times  as  a  kind  of  illustrative 
commentary  on  the  peace  material  that  presents  itself  in 
general  practice  or  in  psychopathic  hospital  voluntary, 
temporary-care,  and  out-patient  practice,  I  chose  to  arrange 
the  delimiting  material  according  to  the  order  of  the  practical 
key  devised  for  civilian  practice.  We  may  now  profitably 
change  our  order  of  consideration  and  consider  whether 

41.  The  most  practical  key  or  sequence  of  consideration 
in  the  endeavor  to  delimit  Shell-shock  neuroses  is  probably : 
Exclude  (i)  syphilis,  (2)  epilepsy,  (3)  somatic  disease  (of  a 
sort  able  to  produce  "symptomatic"  effects  somewhat  like 
those  of  Shell-shock) . 

*  In  the  limited  non-encephalic  sense  of  the  term  somatic 
("  symptomatic  ")  of  some  writers. 


848  EPICRISIS 

Below  I  shall  still  permit  myself  some  general  words  con- 
cerning the  other  more  easily  excluded  groups  because  of  the 
light  which  feeble-mindedness,  alcoholism,  schizophrenia, 
cyclothymia,  and  even  old  age  can  theoretically  throw  on  the 
nature  of  Shell-shock. 

42.  Suppose  then  that  syphilis,  epilepsy,  and  somatic 
(non-ner\-ous)  disease  are  out  of  the  running,  we  come  prac- 
tically down  to  the  psychoneuroses,  knowing  that  knotty 
problems  are  at  hand  in  telling  them  from  structural  trau- 
matic effects:  But,  after  all,  what  are  functional  neuroses? 
What  do  we  really  know  about  the  neuroses  other  than  to 
say  that  they  are  not  distinguished  by  the  existence  of  the 
structural  lesions  which  characterize  organic  disease  of  the 
ner\-ous  system?  Is  not  the  definition  of  neurosis  purely  by 
negatives?  However  true  this  definition  by  negatives  may 
be  from  the  genetic  and  general  pathological  viewpoint,  the 
work  of  Charcot  and  in  particular  of  Babinski  has  yielded  a 
number  of  positive  features  from  the  clinical  viewpoint, 
which  to  some  degree  make  up  for  the  lack  of  anything  posi- 
tive in  the  neurones  themselves  as  studied  post-mortem. 
An  eminent  German  has  recently  declared  that  the  data 
of  this  war  itself  go  far  to  prove  some  of  the  long  dubious 
contentions  of  the  Frenchman,  Charcot;  and  the  work  of 
Babinski  during  the  war  has  strengthened  and  developed  the 
conceptions  of  his  master,  Charcot,  as  well  as  the  ante-bellum 
conceptions  of  Babinski  himself. 

43.  Let  me  insist  that  the  problem  is  practical  enough: 
Organic  versus  functional  neurosis.  The  point  I  want  to 
make  is  that,  when  so  much  theoretical  doubt  concerning 
organic  and  functional  neuropathy  holds  sway,  the  practical 
doubts  in  the  individual  case  under  the  varying  conditions  of 
civilian  practice  and  in  the  upheavals  of  military  practice, 
must  be  still  more  in  evidence.  Case  after  case  described  in 
the  literature  of  every  belligerent  has  passed  from  pillar  to 
post  and  from  post  to  pillar  before  diagnostic  resolution  and 
therapeutic  success.  Colleagues  meeting,  for  example,  at 
the  Paris  Neurological  Society,  find  themselves  reporting 
the  same  case  from  different  standpoints,  —  the  one  an- 
nouncing a  semi-miraculous  cure  of  a  case  which  another  had 


EPICRISIS  849 

months  before  claimed  only  as  a  diagnostic  curiosity.  In 
the  midst  of  such  discussions  and  controversies,  there  must 
inevitably  be  a  renaissance  in  neurology. 

44.  In  cases  of  alleged  Shell-shock,  the  hypothesis  of 
focal  structural  damage  to  the  nervous  system  or  its  mem- 
branes has  to  be  raised. 

Shell  bursts  and  other  detonations  can  produce  hemor- 
rhage in  the  nervous  system  and  in  various  organs  without 
external  injury.  Thus  a  man  died  from  having  both  his 
lungs  burst  from  the  effects  of  a  shell  exploding  a  meter  away. 
Hemorrhage  into  the  urinary  bladder  has  been  identically 
produced.  Lumbar  puncture  yields  blood  in  sundry  cases  of 
shell  explosion  without  external  wound,  and  Babinski  has  a 
case  of  hematomyelia  produced  while  the  victim  was  lying 
down,  so  that  the  factor  of  direct  violence  through  fall  can 
be  excluded.  In  sundry  cases,  not  only  blood  but  also  lym- 
phocytes have  been  found,  sometimes  in  a  hypertensive 
puncture  fluid. 

45.  Moreover,  in  cases  of  alleged  Shell-shock  there  may 
be  a  combination  of  structural  and  functional  disease. 

A  herpes  or  the  graying-out  of  hair  overnight  can  suggest 
organic  changes.  A  case  may  combine  lost  knee-jerks  (sug- 
gesting organic  disease)  with  urinary  retention  (suggesting 
functional  disorder). 

46.  Again,  there  is  a  group  of  war  neuroses,  especially 
clearly  brought  out  in  cases  of  ear  injury,  in  which  the  func- 
tional disorder  surrounds  the  organic  as  a  nucleus.  But 
these  "  periorganic  "  neuroses  are  no  proof  that  the  neuroses 
in  question  are  organic  in  nature.  Hysterical  anesthesia, 
paralysis,  or  contracture  may  occur  on  the  side  of  the  body 
which  has  received  a  wound:  the  process  of  such  a  peri- 
traumatic  disorder  is,  nevertheless,  a  functional  process. 

47.  But,  when  the  problem  is  statistically  taken,  the  ma- 
jority of  cases  of  alleged  Shell-shock  without  external  wound 
prove  to  be  functional,  as  indicated  by  their  clinical  pictures. 
Thus,  after  a  mine  explosion,  a  man  was  hemiplegic,  tremulous 
and  mute.  After  sundry  vicissitudes,  the  tremors  were  hyp- 
notized away.  Then  the  mutism  vanished,  to  be  supplanted 
by  stuttering.     Finally  the  hemiplegia  remained.     So  far  as 


850  EPICRISIS 

the  mutism  and  the  tremors  went,  this  man  might  belong  in 
the  majority  group  of  Shell-shock  cases,  namely,  the  func- 
tional group.  Assuming  the  hemiplegia  to  be  really  organic, 
we  should  regard  this  man  as  a  mixed  case,  organic  and  func- 
tional. 

48.  But  do  we  not  know  all  we  need  to  know  or  all  we  are 
likely  to  know  about  the  neuroses  already  from  old  civilian 
studies?  There  are  some  cases  without  very  close  relations  to 
the  war:  Thus,  we  conceive  of  (a)  psychoneuroses  incidental 
to  the  war  and  such  that  they  might  very  probably  have 
developed  without  the  entrance  ot  war  factors;  and  on  the 
other  hand,  we  conceive  of  (b)  psychoneuroses  (to  be  dealt 
with  in  extenso  later)  in  which  war  factors  (either  physical 
Shell-shock  or  other  factors)  forcibly  enter.  There  are  in 
this  group  of  incidental  psychoneuroses  12  cases.  The  first, 
described  as  a  constitutional  intimiste,  a  psychasthenic  en 
herbe,  was  one  in  which  a  hallucination  was  developed  in 
the  field,  and  in  which  three  phases  of  a  psychopathic  nature 
—  (a)  over-emotionality,  {b)  obsessions,  (c)  loss  of  feeling  of 
reality — developed.  In  this  case  the  war  work  at  first 
seemed  to  better  the  man's  general  condition,  and  he  gave 
two  years  of  effective  service.  This  officer  in  effect  invented 
his  own  Shell-shock  equivalent  in  a  hallucination  of  Germans 
appearing  in  his  trench.  The  case  may  be  compared  with 
one  described  in  Section  B,  namely,  Case  347:  that  of  a 
Russian  soldier  who  developed  perfectly  characteristic  war 
dreams,  though  his  entire  service  had  been  rendered  in  the 
rear  and  he  had  not  had  experiences  in  action. 

Possibly  Case  171,  that  of  hysterical  fugue,  might  be  re- 
garded as  one  of  Shell-shock,  since  two  shells  burst  near  him 
prior  to  his  fugue.  The  man  had  had  analogous  crises, 
certified  by  Regis,  in  adolescence,  and  had  received  the 
diagnosis  hysteria.  In  this  instance,  we  are  dealing  merely 
with  an  habitual  somnambulist  who  has  a  characteristic 
fugue  following  explosion  of  two  shells.  The  war  is  in  a 
sense  responsible  for  the  fugue,  yet  not  directly,  and  the  fugue 
would,  without  the  stress  and  strain  of  war,  probably  never 
have  developed  (see  sundry  cases  in  the  group  in  which  ante- 
bellum phenomena  are  newly  evoked  in  war:  Cases  286-301). 


EPICRISIS  851 

The  hysterical  psychosis  of  an  Adventist  (Case  172)  might 
be  regarded  as  liberated  by  military  service ;  the  terrible  fear 
of  the  guns  shown  by  the  psychoneurotic  (Case  173)  pro- 
ceeded to  the  point  of  fugue.  A  Shell-shock  victim  whose 
war  bride  was  pregnant,  developed  fugue  with  amnesia  and 
mutism  (Case  174).  Under  hypnosis,  it  appeared  that  his 
fugue  began  with  his  running  away  from  shells.  Case  175 
was  that  of  a  neurasthenic  who  volunteered  and  had  to  be 
sent  back  from  the  front  after  three  months.  In  this  case, 
war  dreams  were  supplanted  by  sex  dreams,  and  the  fear 
of  insanity  became  ingrained.  The  phenomena  here  were 
largely  ante-bellum  and  the  war  brought  them  out  once  more, 
as  might  other  disturbing  experiences. 

Case  176  is  here  introduced  to  show  that  neurasthenia  may 
develop  in  a  man  without  hereditary  taint  or  acquired  soil. 
There  was  a  very  slight  shrapnel  injury  of  the  skull,  which 
somewhat  clouds  the  diagnosis  in  the  case.  Five  months' 
war  experience  brought  out  the  neurasthenia.  Case  177 
deals  with  a  point  in  the  diagnosis  of  psychasthenia,  which, 
according  to  Crouzon,  shows  arterial  hypotension,  a  condition 
important  to  distinguish  from  that  of  pulmonary  tuberculosis 
and  of  Addison's  disease.  Compare  this  case  with  Case 
169:  a  case  of  depression  treated  by  pituitrin.  Case  178 
is  a  case  of  psychasthenia  following  several  months'  service 
by  a  man  who  probably  should  never  have  entered  military 
service. 

Another  case  of  ante-bellum  origin  is  Case  179.  Anti- 
typhoid inoculation  appears  to  have  been  the  initial  factor  in 
the  case  of  neurasthenia  No.  180.  Compare  Case  65,  epi- 
lepsy after  antityphoid  inoculation.  Case  181  was  that  of  a 
non-commissioned  reserve  German  officer  whose  neuras- 
thenia was  distinguished  by  sympathy  with  the  enemy.  He 
did  not  want  to  let  his  men  shoot  at  the  enemy  because  the 
idea  came  forcibly  to  him  that  the  enemy  soldiers  had  wives 
and  children.  This  symptom  of  sympathy  with  the  enemy 
was  also  shown  by  another  German  (Case  229).  Compare 
the  sentiments  of  a  Russian  under  narcosis  (Case  555). 

To  sum  up  concerning  the  small  group  of  psychoneuroses 
presented  in  the  section  on  Psychoses  Incidental  in  the  War, 


852  EPICRISIS 

we  are  dealing  with  cases  in  which  the  phenomena  are  either 
continuous  with  ante-bellum  phenomena,  or  are  of  such  a 
nature  that  they  might  well  have  been  brought  out  by  other 
factors  than  those  of  war.  These  cases  by  the  design  of  their 
choice  throw  little  or  no  light  upon  the  relation  of  physical 
shell-shock  or  its  equivalent  to  the  psychoneuroses,  though 
in  a  few  instances  the  factor  of  shell  explosion  is  not  entirely 
to  be  excluded,  and  in  one  instance  (Case  170)  a  hallucination 
may  be  regarded  as  a  virtual  equivalent  of  an  emotional  shock 
of  great  compelling  power. 

Examples  are  available  of  hysteria  (Cases  171,  172,  173, 
174),  of  neurasthenia  (Cases  175,  176,  179,  180,  and  181), 
and  of  psychasthenia   (Cases   177,    178,   and  possibly   170). 

49.  Let  us  now  contrast  with  these  specified  ante-bellum 
or  non-war  cases  the  situation  which  will  face  us  in  the  war 
group. 

Section  B  contains  174  cases  (Cases  197-370).  Autopsied 
cases  (Cases  197-201)  are  put  first  and  are  followed  by  cases 
in  which  lumbar  puncture  data  are  available  (Cases  202-207). 
A  third  group  of  cases  is  that  in  which  so-called  organic  symp- 
toms are  much  in  evidence,  either  independently  or  in  asso- 
ciation with  functional  symptoms  (Cases  208-219).  There 
follows  a  small  group  of  three  cases  with  shrapnel  wound 
(Cases  220-222),  in  which  hysterical  symptoms  were  promi- 
nent, as  against  the  prevalent  and  correct  conception  that 
wounded  cases  are  not  so  prone  to  psychoneurosis  as  non- 
wounded  cases.  Three  cases  specially  marked  by  tremors 
(Cases  223-225)  follow,  the  last  of  which  gives  the  victim's 
(a  French  artist)  own  account  of  his  feelings.  The  next  two 
cases  (Cases  226  and  227)  give  respectively  a  German  and  a 
British  soldier's  account  of  Shell-shock  symptoms. 

There  then  follows  a  great  group  of  cases  (Cases  228-273) 
arranged  according  to  the  part  of  the  body  chiefly  affected 
by  hysterical  symptoms.  The  arrangement  is  one  of  toe  to 
top,  or  as  one  might  more  technically  say,  cephalad.  This 
cephalad  arrangement  naturally  begins  with  cases  with  symp- 
toms affecting  one  leg  or  foot  (Cases  228-235).  Then  fol- 
low cases  of  paraplegia  (Cases  236-241).  As  we  proceed 
cephalad  then  follow  four  cases  of  the  so-called  hysterical 


EPlCRISIS  853 

bent  back,  or  camptocormia  (Souques).  Then  come  walk- 
ing disorders  (Cases  246-248).  Still  proceeding  cephalad, 
disorders  of  one  arm  and  hand  are  considered  in  a  series  of 
six  cases  (Cases  249-254).  Bilateral  phenomena,  symmetrical 
or  asymmetrical,  follow  in  Cases  255-258.  Now  reaching 
the  head,  we  deal  with  cases  of  deafness  (Cases  259-260),  of 
deafmutism  (Cases  261-263),  of  speech  disorder  (Cases  264 
and  265),  with  two  special  cases  (Cases  266  and  267).  Eye 
symptoms  are  dealt  with  in  a  ser  es  of  cases  (Cases  268-272), 
and  Case  273  deals  with  crania  nerve  disorder  supposed  to 
be  due  to  shell  windage  without  explosion. 

The  idea  of  the  above  arrangement  of  46  cases  (Cases  228- 
273)  is  that  the  reader  dealing  with  cases  of  hysterical  disorder 
due  to  physical  shell-shock,  or  some  equivalent  thereof,  may 
inspect  the  data  in  a  few  analogous  cases  described  more  or 
less  fully  in  the  literature.  By  reference  to  the  index,  the 
reader  will  be  able  to  find  still  further  cases  to  illustrate  the 
symptom  in  question. 

The  next  series  of  cases  (Cases  274-281)  are  to  illustrate 
the  contentions  of  Babinski  concerning  the  elective  exaggera- 
tion of  reflexes  under  chloroform,  and  the  conception  of 
reflex  or  physiopathic  disorders  based  thereon  —  a  topic  to 
which  return  is  made  in  Section  C  on  Diagnosis,  and  elsewhere. 
A  small  group  of  cases  (Cases  282-285)  illustrate  the  delay 
of  Shell-shock  and  kindred  symptoms  in  certain  instances, 
cases  that  suggest  a  refractory  period  of  greater  length  than 
usual,  or  the  interposition  of  some  unusual  factor. 

The  next  group  of  cases  (Cases  286-301)  is  of  special  note, 
bringing  out  what  is  discussed  below,  namely,  the  emphasis, 
reminiscence,  or  repetition  of  antebellum  phenomena,  and 
the  picking  out  of  weak  spots  in  the  organism  by  Shell-shock. 
Possibly  Cases  302-303  belong  in  the  same  group  of  illustra- 
tions of  the  driving  in  of  ante-bellum  effects.  Cases  304  and 
305  are  definitively  cases  in  which  hereditary  instability  is  a 
factor,  whereas  Cases  306  and  307  form  a  foil  to  these,  in  that 
the  phenomena  develop  in  subjects  confidently  stated  to  be 
without  hereditary  or  acquired  psychopathic  tendency. 

The  next  series  of  cases  (Cases  308-320)  shows  peculiar 
phenomena;   e.g.,  monocular   diplopia,  shell-shock  psoriasis, 


854  EPicRisis 

synesthesia,  puerilism,  and  the  like.  Shell-shock  equiva- 
lents of  various  sorts  are  placed  in  a  group  of  cases  (Cases 
321-325).  The  next  series  of  cases  (Cases  326  to  the  end  of 
this  Section:  370)  show  tendencies  to  general  neurasthenic, 
psychasthenic,  and  other  psychopathic  phenomena,  rather 
than  the  more  defin  te  phenomena  discussed  in  the  early  part 
of  this  section  in  the  series  arranged  "  cephalad." 

50.  Rehearsing  more  briefly  these  findings,  What  is  the 
nature  of  these  disorders?  The  literature  is  practically  unani- 
mous on  the  point :  We  have  to  do  merely  with  the  classical 
problem  of  the  neuroses,  and  when  all  the  data  are  some  day 
united,  we  shall  doubtless  know  a  great  deal  more  about  the 
neuroses. 

51.  Locus  minoris  resistentiae.  That  the  process,  what- 
ever else  it  does,  is  rather  apt  to  pick  out  pre-existent  weak 
spots  in  the  patient  (the  habitual  gastropath  becoming  sub- 
ject to  vomiting;  the  old  stammerer  stammering  once  more 
or  even  becoming  mute;  the  man  always  "  hit  in  the  legs  " 
by  exertion,  now  becoming  paraplegic)  is  obvious.  The 
striking  instances  in  which  an  old  cured  syphilitic  monoplegia, 
or  an  old  hysterical  hemichorea,  comes  back  under  the  in- 
fluence of  shell  explosion  in  precisely  the  limits  and  with 
precisely  the  appearance  of  the  former  disease,  indicate  how 
various  a  factor  may  be  the  locus  minoris  resistentiae. 

52.  But,  without  weak  spot,  without  acquired  soil,  without 
heredity,  we  must  now  erect  the  hypothesis  that,  the  classical 
neuroses  may  in  some,  though  certainly  a  minority  of  cases, 
afflict  normal  men.  Under  the  war  conditions  of  investi- 
gation touching  the  family  and  personal  histories  of  the  men, 
perhaps  we  should  not  be  too  sure  of  this  hypothesis ;  but  the 
army  records  w  11  after  the  war  allow  us  to  make  or  break  the 
point  forever  and  thereby  throw  the  clearest  light  upon  the 
vexing  problems  of  industrial  medicine,  wherein  progress  in 
general  has  been  so  slow  on  account  of  the  partisanship  of 
the  corporation  and  plaintiff's  attorneys. 

53.  Purely  psychogenic  war  cases  exist:  Though  Shell- 
shock  denotes,  to  say  the  least,  shocks  and  shells  —  yet  we 
know  Shell-shock  sans  any  shock  and  sans  any  shell,  nay 
sans  either  shell  or  shock. 


EPICRISIS 


>00 


The  fact  that  a  soldier  may  get  war  dreams  though  he  has 
3ver  been  in  the  fighting  zone  and  never  by  any  chance  ob- 
irved  the  circumstance  of  war,  or  the  fact  that  a  man  can 
ecome  mute  on  the  second  day  after  a  shell  explosion  be- 
ause  the  night  before  he  had  dreamed  of  some  hysterically 
nute  patients  in  his  ward  —  these  facts  again,  although  they 
irgue  a  psychogenic  origin  for  the  phenomena  of  so-called 
"  Shell-shock,"  do  not  at  all  mean  that  actual  physical  ex- 
plosion in  other  cases  may  not  be  tremendously  important. 

54.  This  is  shown  by  the  exceedingly  interesting  phenom- 
ena of  localization  or  determination  of  symptoms  to  a  given 
region  under  the  special  local  influence  of  the  explosion.  Thus, 
in  the  schematic  case,  an  explosion  to  the  left  of  the  soldier 
produces  anesthesia  and  paralysis  on  the  left  or  exposed  side. 
Now  and  again  a  case  will  show  such  anesthetic  and  paralytic 
phenomena  upon  the  side  exposed  to  the  explosion  and  some 
hypertonic,  irritative  phenomena  upon  the  other  side.  One 
gets  the  figure  in  one's  mind  of  an  organism  fixed,  immobile 
and  numb,  on  the  spot  by  the  explosion  —  and  the  other  half 
of  the  body,  as  it  were,  attempting  to  run  away  from  the 
situatiqn.  One  side  of  the  body,  as  it  were,  plays  'possum, 
the  other  tends  to  flight. 

55.  Of  course  these  physical  phenomena  should  not  blind 
us  to  the  emotional  ones.  Now  and  then  the  multiple  causes 
of  a  case  may  be  analyzed,  as,  for  example,  one  of  blindness  in 
which  a  series  of  factors  emerged,  such  as  excitement,  blind- 
ing flashes,  fear,  disgust  and  fatigue.  I  cannot  here  go 
further  into  these  details,  and  I  need  no  longer  nsist  upon  the 
fact  that  surrounding  the  problem  of  Shell-shock  means 
surrounding  the  problem  of  nervous  and  mental  diseases 
as  a  whole,  and  that  thus  to  be  a  Shell-shock  analyst  means 
to  be  a  neuropsychiatrist. 

56.  The  organic  problems  of  the  nervous  system  are 
brought  up  constantly  In  differential  diagnosis,  but  the 
functional  problems  divide  themselves  up  in  a  perturbing 
manner  into  a  fraction  properly  termed  the  "  psychopathic  " 
(that  Is,  after  the  manner  of  hysteria),  and  "  non-psycho- 
pathic "  (that  is,  after  the  manner  of  reflex  disorders  of 
Charcot,  newly  named  "  physiopathic  "  by  Babinski). 


856  EPICRISIS 

57.  For  the  moment  we  are  not  discussing  differential 
diagnosis,  but  are  merely  trying  to  circumscribe  the  features 
we  wish  to  call  Shell-shock  features :  We  have  concluded  to 
call  them  functional  —  but  what  is  it  to  be  functional? 

Too  simple  is  the  reply: 

Functional  =  Non-Organic. 
Inaccurate  and  misleading  is  the  reply 

Functional  =  Psychic. 
We  may  more  correctly  express  the  situation,  pathologi- 
cally speaking,  in  the  following  categories  (see  chart,  page  870) : 
;ORGANOPATHIC  (Lesional,  destructive) : 

(a)  gross,  or  (b)  microscopic,  or  perhaps  (c)  chemical. 
DYNAMOPATHIC   (functional,  irritative,   inhibitory, — 
but  reversible  ad  originem) : 
(a)  psychopathic;   {b)  physiopathic  ("  reflex  "). 

58.  As  to  the  high  psychic  functions,  we  had  thought  of 
them  as  split  in  hysteria,  in  dissociation  of  personality.  And 
we  had  roughly  distinguished  these  conditions  as  psycho- 
pathic from  conditions  we  called  neuropathic,  regarding  the 
latter  neuropathic  disorders  as  on  the  model  of  the  effects  of 
cutting  off  or  destroying  certain  necessary  neurons.  How- 
ever clear  or  unclear  we  were  as  to  the  nature  of  the  neuro- 
pathic, it  does  not  here  matter.  Babinski's  point  is  that 
there  is  another  kind  of  dynamic  disease  that  operates,  noi 
after  the  manner  of  hysteria,  but  after  a  manner  reminding 
one  of  the  forgotten  "reflex"  disorders  of  Charcot  —  dis- 
orders that  fitted  the  textbooks  so  poorly  that  the  textbooks 
dropped  them  out.  In  short,  what  you  might  call  the 
dynamopathic  or  functional  in  nervous  disease  has  been 
shown  to  fall  into  two  parts  —  a  psychopathic  fraction  and 
a  non-psychopathic  fraction.  Bablnski  calls  this  non-psy- 
chopathic fraction  physiopathic  or  reflex.  And  these  reflex 
or  physiopathic  disorders  have  a  different  order  of  curability 
from  that  of  hysterical  or  psychopathic  disorders.  By  what 
simple  device  did  Bablnski  prove  this?  By  chloroforming 
the  patient.  Under  chloroform,  when  all  the  other  reflexes 
were  stilled,  Bablnski  could  bring  out,  in  relief  as  it  were, 
certain  reflexes,  or  even  hypertonuses,  that  were  in  the  waking 


EPICRISIS  857 

life  wholly  concealed,  — yet  at  the  same  time  consciousness, 
in  the  usual  sense  of  that  term,  had  vanished.  Accordingly, 
the  proof  of  a  new  type  of  functional  disease,  at  times  con- 
cealed by  the  overlay  of  higher  neurones,  was  now  plain. 
Does  not  this  offer  new  leads  of  the  greatest  value  in  that 
most  intricate  of  fields,  psychopathology?  Is  not  the  model 
here  offered  of  diseased  nervous  functions,  non-psychic  in 
nature  (in  the  ordinary  sense  of  psychic)  but  of  almost  equally 
complex  nature; 

Whoever  wins  the  great  war  from  the  mil'tary  point  of 
view,  there  can  be  no  doubt  as  to  what  writers  contributed 
most  from  the  war  data  concerning  the  doctrine  of  hysteria, 
especially  concerning  the  theoretical  delimitation  of  hysteria 
from  other  forms  of  functional  nerv^ous  disease:  There  can 
be  no  other  answer  than  that,  in  theoretical  neurology  at  least, 
the  French  have  already  won  the  war,  if  only  by  means  of 
the  remarkable  concept  set  up  by  Babinski  of  the  so-called 
physiopathic  (that  is,  non-neuropathic  and  non-psycho- 
pathic) . 

But  how  has  this  splitting  of  functional  neuroses  into 
psychopathic  and  physiopathic  been  rendered  certain?  By 
the  tremendous  modern  sharpening  of  differential  diagnosis 
dating  from,  e.g.,  the  discovery  of  the  Babinski  reflex.  This 
brings  us  to  the  brink  of  considerations  concerning  the 
differential  diagnostic  problem. 

First  it  may  be  well  to  regard  the  whole  problem  in  the 
light  of  those  mental  diseases  that  we  slid  over  when  we  were 
delimiting  Shell-shock  as  against  syphilis,  epilepsy  and 
somatic  disease. 

59.  Why  do  some  authors  think  of  Shell-shock  as  an 
**  officer's  disease  "  ?  It  is  clear  that  they  cannot  be  thinking 
so  much  of  the  physiopathic  cases  as  of  the  psychopathic  ones. 
But  psychopathic  conditions  are  obviously  more  readily 
brought  about  in  complex  and  labile  apparatus.  This 
point  comes  out  strongly  in  relation  with  the  comparative 
stability  of  the  feeble-minded,  at  least  of  most  feeble-minded, 
that  get  into  war  relations. 

The  possible  relations  of  Shell-shock  to  feeble-mindedness 
are  of  some  Interest.     We  know  that  Shell-shock  picks  out 


8.58  EPiCRisis 

certain  nervous  and  mental  weaklings  and  indeed  that  one 
author  claims  as  high  a  percentage  as  74  for  war  neuroses 
having  a  hereditary  or  acquired  neuropathic  basis.  How  far 
does  feeble-mindedness  itself  count  among  these  supposedly 
susceptible  nervous  and  mental  weaklings?  Is  a  feeble- 
minded person  especially  in  condition  for  Shell-shock? 

There  are  rumors  of  experiments  to  show  that  if  in  an 
aquarium  containing  some  jelly  fish  alongside  bony  fishes, 
you  explode  a  substance,  the  jelly  fish  ride  through  unscathed 
whereas  the  bony  fishes  are  killed  by  the  shock.  The  jelly 
fish  presumably  had  too  simple  an  organization. 

There  is  something  to  be  said  for  the  idea  that  in  man  also 
the  higher  and  more  complex  specimens  are  more  susceptible 
to  Shell-shock,  that  is,  to  the  neuroses  of  war,  than  are  the 
lower  and  more  simple  combatants.  Some  statistics  indicate 
that^ofiicers,  who  are  in  the  main  of  a  higher  and  more  com- 
plex organization  than  the  private  soldiers,  are  much  more 
susceptible  than  are  private  soldiers  to  the  neuroses  of  war. 
Doubtless  we  shall  not  be  able  to  verify  these  statistics  until 
long  after  the  war  and,  so  far  as  I  know,  no  very  inclusive 
statistics  have  been  presented. 

On  the  whole,  I  judge  from  the  case  history  literature  that 
the  feeble-minded,  unless  they  be  of  that  very  high  level 
sometimes  called  subnormal,  are  not  particularly  susceptible 
to  the  neuroses.  It  is  obvious  that  idiots  and,  for  the  most 
part,  imbeciles,  do  not  get  into  military  service.  As  for 
what  the  English  term  the  feeble-minded  or  what  we  in 
America  are  now  terming  morons,  it  may  well  be  that  our 
draft  boards  do  not  always  exclude.  High  French  author- 
ities have  specifically  determined  in  certain  instances  that 
the  high-grade  feeble-minded  would  be  perfectly  suitable  for 
certain  branches  of  the  service.  There  is  the  case,  for  ex- 
ample, of  a  sandwich  man  of  Paris  who  somehow  got  into 
the  French  army  and  was  being  perpetually  sent  to  look  for 
the  squad's  umbrella  and  the  key  to  the  drill  ground,  but 
sang  and  swung  his  gun  with  joy  as  he  went  to  the  front,  and 
apparently  did  very  well  there.  This  man  had  been  a  state 
ward  and,  as  you  know,  well- trained  state  wards  are  frequently 
exceedingly  good  at  elementary  forms  of  drill. 


EPICRISIS  859 

Then  there  is  another  case  of  an  obvious  imbecile  who  was 
quite  without  any  idea  of  mihtary  rank  and  often  got  pun^ 
ished  for  treating  his  superiors  Hke  his  comrades  and  was  the 
butt  of  his  section,  but  on  the  firing-Hne  remained  cool,  care- 
less of  danger  —  a  magnificent  example  to  his  comrades  — 
at  last  surrounded  and  taken  prisoner.  Here  the  story  might 
have  ended  and  the  folly  of  enlisting  imbeciles  in  the  army 
might  have  seemed  perfectly  plain,  except  that  our  imbecile 
forthwith  escaped  from  the  Germans,  swam  the  Meuse  and 
got  back  to  his  regiment! 

Here  then  are  cases  in  which  the  slight  degree  of  hypo- 
phrenia  —  it  seems  unwise  to  give  it  the  opprobrious  title 
"  feeble-mindedness  " — would  have  been  entirely  incon- 
sistent with  the  development  of  Shell-shock.  Such  men  are, 
perhaps,  too  sunple  to  develop  neuroses.  On  the  other  hand, 
it  would  appear  that  certain  of  the  slight  degrees  of  hypo- 
phrenia,  such  as  we  might  find  in  so-called  subnormal  or 
stupid  persons,  would  prove  capable  of  "catching  Shell-shock" 
as  it  were,  and  then  find  themselves  entirely  incapable  of 
rationalizing  the  situation.  In  short,  there  may  be  a  group  of 
psychic  weaklings,  just  complex  enough  to  fall  into  the  zone 
of  potential  neurotics,  but  just  simple  enough  to  render  the 
processes  of  rationalization  (or  what  one  author  terms  autog- 
nosis)  and  of  psychotherapy  in  general  entirely  unavailing. 

After  the  war  we  may  be  confronted  with  a  number  of 
persons  with  their  edges  dulled  by  the  war  experiences.  One 
has  met  even  brave  ofhcers  who,  after  months  of  furlough, 
still  maintain  that  they  will  never  get  back  to  their  normal 
will  and  initiative.  Whether  these  hypoboulic  persons  have 
not  been  reduced  to  subnormality  so  as  to  resemble  the 
slighter  degrees  of  hypophrenia  or  feeble-mindedness  can 
hardly  be  determined  now.  They  will  form  important  prob- 
lems in  mental  reconstruction,  for  with  the  best  will  in  the 
world,  the  occupation-therapeutist  with  all  her  technic,  may 
be  unable  to  force  or  coax  the  will  of  such  hypoboulics  into 
proper  action.  Nor  will  the  ordinary  environment  of  home 
and  neighborhood  turn  the  trick  properly.  Expert  social 
work  in  adjustment,  both  of  the  returned  soldier  to  his  en- 
vironment and  of  the  environment  to  the  returned  soldier, 


86o  EPICRISIS 

may  be  necessary.  I  speak  of  this  problem  here  not  because 
these  persons  are  hypophrenic  or  feeble-minded  in  the  ordi- 
nary sense,  but  we  must  constantly  bear  in  mind  our  experi- 
ence in  the  teaching  of  hypophrenics  (both  in  the  schools  for 
the  feeble-minded  and  in  the  community)  when  we  are  facing 
problems  of  mental  reconstruction. 

60.  As  for  alcoholism,  Lepine's  figures  bespeak  its  im- 
portance as  a  hospital-filler  and  a  good  deal  of  prime  interest 
surrounding  alcoholism  has  been  developed  in  the  war;  but 
on  the  whole,  so  far  as  I  can  determine  from  the  war  case 
literature,  there  is  little  or  no  direct  relation  between  alco- 
holism and  Shell-shock,  despite  the  fact  that  in  a  number  of 
instances  alcohol  has  complicated  the  issue  and  very  possibly 
helped  in  a  general  demoralization  of  the  victim.  However, 
the  alcoholic  amnesias  and  particularly  a  few  instances  of  the 
so-called  pathological  intoxication  have  exhibited  a  certain 
medicolegal  interest,  recalling  what  was  just  said  above  about 
the  responsibility  of  a  drunken  epileptic.  Alcohol  remains, 
I  should  say,  pending  exact  monographic  work  upon  this 
topic,  purely  a  contributory  factor  for  the  war  neuroses. 

It  must  be  that  the  exigencies  of  the  war  have  prevented 
full  reports  of  alcoholic  cases ;  or  perhaps  they  are  regarded  as 
of  such  every-day  occurrence  as  not  to  demand  case  reports. 
The  alcohol  and  drug  group  is  represented  by  1 7  cases  (Cases 
86-102). 

The  so-called  pathological  intoxication  is  illustrated  in 
Cases  86  and  87.  Case  86  was  entirely  amnestic  for  an 
attack  of  hallucinations  in  which  he  tried  to  transfix  comrades 
with  a  bayonet.  Cases  87-97  are  cases  of  disciplinary  nature, 
—  the  majority  from  a  German  writer,  Kastan.  Case  88 
illustrates  desertion  in  alcoholic  fugue,  and  Cases  90-92  are 
three  further  cases  of  desertion  in  alcoholism. 

Cases  94  and  95  give  a  partial  explanation  of  some  German 
atrocities.  At  least,  here  are  cases  in  which  the  atrocities, 
with  attempted  murder  and  rape,  are  described  more  or  less 
fully  in  transcripts  of  medicolegal  reports.  Case  98  throws 
a  curious  cross-light  upon  the  war,  in  that  a  drunken  soldier 
got  an  unmerited  long  leave  after  paying  100  sous  for  an 
injection  of  petrol  in  his  hand.     Cases  99-102  are  cases  of 


EPICRISIS  86i 

morphinism,  illustrating  the  effects  of  the  war  upon  the  fate 
of  morphinists. 

6i.  That  war  makes  nobody  go  mad  In  the  asylum  or  lay 
sense  of  the  term  has  been  abundantly  proved  by  the  data 
of  this  war  —  and  this  conclusion  is  of  value  in  our  medical 
endeavors  to  establish  a  proper  lay  conception  of  the  nature 
of  Shell-shock.  Consider  first  schizophrenia  (dementia  prae- 
cox). 

That  the  causes  of  dementia  praecox,  still  unknown  as  they 
are,  lodge  more  in  the  interior  of  the  body  or  in  special  in- 
dividual reactions  of  the  victim's  mind,  seems  to  be  shown  by 
the  phenomena  of  this  war,  since  there  seems  to  be  no  great 
number  of  dementia  praecox  cases  therein  produced.  To  be 
sure,  some  schizophrenic  subjects  do  get  into  the  service,  and 
sometimes  their  delusions  and  hallucinations  get  their  content 
and  coloring  from  the  war.  Thus  a  Russian,  wounded  in  the 
army,  developed  delusions  concerning  currents  running  from 
his  arm  to  the  German  lines  and  felt  that  he  was,  so  to  say, 
the  Jonah  of  the  Russian  front,  as  he  could  determine  shell 
fire  to  the  spot  where  he  was  by  the  arm  currents. 

Now  and  then  a  case  shows  a  scientifically  beautiful  ad- 
mixture of  ordinary  dementia  prsecox  phenomena  with  the 
effects  of  shell  wound  or  shock.  A  picturesque  case  from  the 
standpoint  of  German  psychiatric  diagnosis  is  one  of  a  soldier 
who  boxed  the  ear  of  a  kindly  sister  who  tried  to  steer  him 
from  a  room  where  the  examination  of  another  patient,  a 
woman,  was  going  on.  On  the  whole,  the  eminent  German 
psychiatrist  who  examined  him  felt  that  the  case  was  really 
one  of  psychopathic  constitution,  as  he  had  shown  somewhat 
similar  irascibility  on  a  slight  occasion  before.  However, 
much  to  the  astonishment  of  all,  the  patient  developed  further 
symptoms.  His  ego  got  terribly  swollen.  At  last  he  was 
fain  to  utter  a  denunciation  of  the  entire  Junker  turn  and  of 
the  Kaiser:  he  said  in  fact  that  he  was  an  Inhabitant  of  the 
World  and  not  of  Prussia  merely.  Over  here  we  allow  such 
persons  to  edit  newspapers  and  write  books  with  impunity, 
but  the  eminent  German  psychiatrist,  before  mentioned,  was 
constrained  to  alter  his  diagnosis  of  this  cosmopolite  from 
psychopathic  constitution  to  dementia  praecox! 


862  EPICRISIS 

The  group  is  represented  by  i6  cases  (Cases  147-162). 

62.  There  are  four  cases  (Cases  1 48-151)  of  a  disciplinary 
nature.  The  first  (Case  148)  was  actually  arrested  as  a  spy 
because  he  was  making  drawings  near  a  petroleum  tank.  Of 
two  cases  of  desertion,  one  was  due  to  a  fugue  of  catatonic 
nature  (Case  149),  and  the  other  (Case  150)  was  one  of 
desertion  with  behavior  suggesting  schizophrenia.  However, 
this  man  was  determined  to  be  responsible  for  his  act,  and 
condemned  to  20  years  in  prison.  This  latter  case  might  be 
considered  also  in  connection  with  Group  III  (the  epilepsies), 
Group  IV  (the  pharmacopsychoses),  and  possibly  Group  XI 
(the  unresolved  psychopathias) . 

Case  151  was  likewise  alcoholic  and  disciplinary:  the  man 
went  so  far  as  to  keep  a  cigar  in  his  mouth  while  the  captain 
was  rebuking  him  and  was,  in  fact,  an  old  sanatorium  case, 
afflicted  with  some  sort  of  degenerative  disease,  presumably 
dementia  praecox. 

63.  That  schizophrenic  symptoms  may  be  aggravated  by 
service  is  shown  likewise  in  the  case  that  follows,  namely, 
Case  152,  a  man  who  had  been  hearing  false  voices  for  some 
two  years,  had  heard  his  own  thoughts,  and  felt  his  personality 
changing.  The  military  board  decided  that  the  mental 
disease  had  been  aggravated  by  service.  Case  153  might 
offhand  be  regarded  as  a  malingerer,  as  he  shot  himself  in 
the  hand.  Upon  military  review,  a  delusional  state  set  in, 
and  in  the  course  of  no  very  long  time  a  state  of  schizophrenic 
apathy.  In  point  of  fact,  however,  this  man  had  already  been 
in  several  hospitals  for  previous  examination,  and  had  served 
in  the  army  in  relatively  normal  intervals.  Case  154  is 
that  of  a  dementia  praecox  who  volunteered  for  three  years 
in  French  infantry  but  forthwith  gave  indications  of  mental 
deterioration.  This  case  of  a  dementia  praecox  volunteer 
may  be  compared  with  Case  36:  that  of  a  superbrave  im- 
becile who  swam  the  Meuse,  back  from  a  German  prison; 
with  Case  47,  that  of  the  feeble-minded  person  with  an  in- 
subordinate desire  to  remain  at  the  front;  with  Case  163, 
a  maniacal  volunteer;  and  Case  175,  a  neurasthenic  volunteer. 

64.  Diagnostic  questions  are  brought  up  by  Cases  155- 
166,  in   the   former  of   which    BonhoefTer  made   at   first    a 


EPICRISIS  863 

diagnosis  of  some  form  of  psychogenic  disease,  possibly 
hysterical,  but  had  eventually  to  alter  the  diagnosis  to  hebe- 
phrenia or  catatonia.  Case  156  was  possibly  one  of  Shell- 
shock,  though  the  man  remained  on  duty  for  a  month  with 
but  one  symptom,  trembling  of  the  arm.  For  nine  months 
he  showed  a  variety  of  symptoms  apparently  consistent  with 
the  diagnosis  hysteria,  but  then  developed  catatonic  and 
paranoic  symptoms  clearly  warranting  the  diagnosis  dementia 
praecox. 

65.  Schizophrenia  may  not  only  be  aggravated  by  service, 
but  as  Case  157  shows,  war  experience  may  have  a  definite 
effect  upon  the  content  of  hallucinations  and  delusions. 
Thus,  a  man  wounded  in  the  left  shoulder  built  up  the  idea 
of  currents  running  from  his  left  arm  to  the  Germans,  such 
that  if  anything  were  touched  by  the  arm,  bombardment  of 
the  Russians  would  at  once  start  up.  The  arm,  in  short,  was 
charmed. 

66.  Psychopathic  bravery  is  not  shown  in  the  feeble- 
minded only:  Case  158  is  that  of  an  Iron  Cross  winner  who, 
after  an  hysterical-looking  attack  with  hallucinatory  reminis- 
cences of  a  Gurkha  whom  he  had  bayoneted,  turned  out  to 
be  hebephrenic.  Case  159  might  at  first  sight  have  been 
placed  among  the  encephalopsychoses  on  account  of  the 
trauma  to  the  occiput,  and  in  fact  the  mystical  hallucinations 
shown  were  of  a  visual  nature  (a  rainbow-colored  bird  with 
the  face  of  the  Holy  Mrgin).  In  point  of  fact,  there  was 
probably  no  causal  relation  between  the  mystical  delusions 
and  the  brain  injury. 

67.  Case  156,  above  mentioned,  might  perhaps  be  inter- 
preted as  one  of  Shell-shock  dementia  praecox,  but  the  in- 
terval of  nine  months,  though  filled  with  hysterical  symptoms, 
is  decidedly  long  in  which  to  suppose  that  shell-shock  factors 
could  be  in  process  of  causing  dementia  praecox.  Cases 
160  and  161  are  more  suspicious.  Six  German  soldiers  were 
killed  by  a  German  shell  within  the  zone  of  German  fire,  two 
steps  away  from  the  subaltern  officer  (Case  160),  who  carried 
on  for  some  hours,  made  his  report  duly,  but  thereafter  de- 
veloped tremors  and  lost  consciousness.  According  to  Wey- 
gandt,  the  case  is  one  suggestive  of  dementia  praecox,  but 


864  EPiCRisis 

very  possibly  should  be  regarded  as  one  of  psychoneurosis. 
At  all  events,  it  would  be  dangerous  to  found  a  doctrine  to 
the  effect  that  dementia  praecox  can  be  initiated  by  shell- 
shock  upon  such  a  case  as  i6o.  Case  i6i  is  similarly  doubt- 
ful. There  are  a  number  of  symptoms  in  this  man  (the  sole 
survivor  of  an  explosion  in  a  blockhouse)  consistent  with  the 
diagnosis  Shell-shock,  and  a  number  of  others  which  hardly 
can  be  given  any  other  interpretation  than  that  of  catatonic 
dementia  praecox.  But  the  available  medical  data  do  not 
begin  until  five  months  after  the  shell  explosion.  We  must 
conclude  here  also  that  no  definite  evidence  exists  that 
dementia  praecox  can  be  initiated  by  the  physical  factor 
shell-shock.  Case  162  is  one  in  which  there  are  shell-shock 
factors  and  fatigue  factors  in  a  man  who  had  once  ante- 
bellum shown  signs  of  mental  disorder,  and  who  developed 
delusions  subsequent  to  a  fugue  following  shell-shock.  The 
most  one  could  make  of  this  case  would  be  to  say  that  a  latent 
schizophrenia  had  been  liberated  by  shell-shock. 

68.  To  sum  up  concerning  the  schizophrenias  (dementia 
praecox  group),  there  are  cases  of  great  disciplinary  interest 
in  which  alleged  espionage  and  desertion  turn  out  actually 
to  be  schizophrenic  phenomena.  Again,  there  are  interesting 
diagnostic  problems  in  the  differential  diagnosis  of  hysteria 
and  catatonia.  There  is  evidence  that  experience  in  the  war 
may  be  woven  into  the  hallucinatory  and  delusional  contents 
of  cases  of  pre-existent  psychosis. 

69.  As  to  the  important  question  whether  shell-shock  can 
initiate  dementia  praecox,  the  evidence  from  these  reported 
cases  is  against  the  hypothesis;  but  if  the  query  be,  w^hether 
Shell-shock  might  not  aggravate  dementia  praecox,  it  may 
be  stated  that  a  military  board  has  decided  that  dementia 
praecox  may  be  aggravated  by  some  forms  of  military  service. 
There  is  no  reason  to  suppose  that  shell-shock  factors  might 
not  operate  in  this  way.  Cases  152  and  162  will  be  of  ser- 
vice in  the  proof  of  this  contention;  and  Case  162  seems  to 
be  definitely  one  in  which  a  latent  schizophrenia,  showing 
itself  in  one  ante-bellum  attack,  was  liberated  once  more 
after  shell-shock.  Of  course,  the  plan  of  this  book  and  the 
method  of  choice  of  its  cases  precludes  any  statistical  con- 


EPICRISIS  865 

elusions  of  great  weight  from  the  relative  number  of  cases 
found  in  the  different  groups ;  and  it  might  well  happen  that 
psychiatrists  would  not  report  cases  of  an  everyday  and  com- 
monplace nature  which  might  yet  be  very  frequent.  On  the 
whole,  however,  it  would  not  appear  that  dementia  praecox 
is  at  all  a  frequent  phenomenon  in  the  war. 

70.  Nor  can  the  cyclothymias  (manic-depressive  psychoses) 
be  charged  up  to  war  factors  to  any  important  extent. 

On  account  of  the  somewhat  close  resemblance  between  the 
phenomenon  of  manic-depressive  psychosis  and  what  we 
ordinarily  feel  ourselves  —  a  logical  situation  reflecting  merely 
the  fact  that  the  phenomena  of  over-activity  (mania)  and 
of  under-activity  (depression)  are  merely  quantitative  vari- 
ations from  the  normal  —  it  might  be  supposed  that  the  war 
life  and  its  shock  and  strain  would  start  up  the  cyclothymias 
in  some  numbers.  Why  should  not  a  shell  explosion  start  up 
a  mania  or  throw  a  man  into  a  depression?  In  point  of  fact 
the  literature  somehow  does  not  agree  with  this  presupposition. 

Some  years  ago  in  Massachusetts  a  brief  investigation  was 
made  of  the  assigned  causes  of  the  successive  attacks  in  a 
great  number  of  cyclothymic  (manic-depressive)  cases,  and  it 
was  found  that  each  successive  attack  progressively  had  less 
of  the  physical  in  the  previous  history.  Something  like  45% 
of  all  the  first  attacks  had  a  pretty  obvious  cause  in  the 
soma,  such  as  a  kidney  disease,  a  heart  disease,  a  puerperal 
condition  and  the  like,  but  the  second  attacks  failed  to  show 
even  20%  of  such  obvious  somatic  causes,  and  the  third 
attacks  even  less  than  10%,  and  so  on. 

Now  war  conditions  and  even  the  shell  explosions  them- 
selves have  apparently  not  set  up  any  such  conditions  as 
those  of  mania  or  of  depression.  Most  of  the  instances  of 
cyclothymia  are  instances  of  men  who  are  cyclothymic  before 
they  enter  the  army.  These  experiences,  when  after  the 
war  we  can  sift  them  all  out,  may  allow  us  to  form  better  ideas 
as  to  the  etiology  of  many  of  the  psychoses,  and  the  great  war 
may  thus  prove  a  gigantic  experimental  reagent  which  will  aid 
in  solving  some  of  the  major  problems  of  mental  hygiene. 

71.  The  cyclothymic  or  manic-depressive  group  is  repre- 
sented in  strikingly  few  cases,  seven  in  number  (Cases  163- 


866  EPiCRisis 

169).  One  of  the  ideas  in  the  hterature  concerning  the 
manic-depressive  group  has  been  that  it  is  very  possibly  re- 
motely allied  to  Graves'  disease,  a  hypothesis  upheld  by 
Stransky  in  Aschaffenburg's  Handbook.  Hyperthyroidism 
itself  has  been,  of  course,  a  rather  striking  feature  in  the  fore- 
ground or  background  of  many  sick  patients  in  the  war. 
However,  war  factors  have  proved  able  to  bring  out  very 
few  instances  of  cyclothymic  (manic-depressi\^e)  disease. 
Amongst  our  seven  cases,  the  first  (Case  163)  was  that  of  a 
maniacal  Alsatian  of  59  years,  who  volunteered  because  of 
his  hypomania.  Case  165,  the  case  of  a  German  who  pelted 
French  trenches  with  apples  from  an  appletree  in  No  Man's 
Land,  was  another  case  in  which  the  war  had  little  or  nothing 
to  do  with  the  development  of  the  mania.  One  of  fugue 
(Case  164)  was  a  case  of  melancholia  and  anxiety  not  closely 
related  with  war  experience.  In  three  further  cases  trench 
life  and  war  stress  may  be  thought  to  have  liberated  the 
cyclothymic  phenomena.  Case  166  was  that  of  a  man  of  38, 
previously  referred  to,  who  developed  arteriosclerosis  and 
whose  depression  and  hallucinations  had  followed  four  months 
of  trench  life  devoid  of  battles  or  injury.  It  is  possible  that 
this  case  should  be  regarded  rather  as  syphilitic  or  of  some 
unknown  organic  origin.  At  all  events,  it  is  not  clear  that 
it  could  be  made  to  bear  a  heavy  weight  of  hypothesis  con- 
cerning the  genesis  of  cyclothymic  psychoses.  Case  167,  a 
naval  officer  who  distinguished  himself  greatly  by  work  on 
land  in  Belgium,  was  regarded  by  its  reporter  as  one  of 
manic-depressive  psychosis  with  the  fatigue  of  war  as  its 
base.  It  might  be  queried  whether  the  man's  distinguished 
work  was  not  due  to  an  early  phase  of  hypomania,  after  which 
the  cyclothymic  effects  began.  In  Case  168  there  was  some 
evidence  of  the  effect  of  war  stress,  as  certain  hallucinations 
grew  more  intense  after  the  bombardment  of  Dunkirk;  but 
in  point  of  fact,  this  man  had  shown  a  predisposition  and  in- 
deed a  period  of  so-called  neurasthenia  ante-bellum.  It  is 
doubtful,  therefore,  whether  there  is  any  case  here  abstracted 
which  can  be  used  to  support  the  hypothesis  that  the  manic- 
depressive  (cyclothymic)  group  of  mental  diseases  has  had  or 
is  likely  to  have  its  genesis  in  war  stress.     The  remaining 


EPICRISIS  867 

case  (Case  169)  is  one  illustrating  a  method  of  treating  low 
blood  pressure  in  depression. 

To  sum  up  concerning  the  cyclothymias :  War  stress  seems 
to  have  had  singularly  little  effect  in  the  production  of  fresh 
attacks,  and  so  far  as  we  are  aware,-  no  effect  in  starting  up  a 
manic-depressive  diathesis,  unless  Case  167, — that  of  the 
naval  officer  who  distinguished  himself  in  land  battles,  — 
looks  in  that  direction.  It  is,  of  course,  to  be  conceded  that 
hypomania  might  readily  be  overlooked  under  war  conditions, 
and  that  suicidal  melancholias,  belonging  in  this  group,  might 
be  interpreted  as  natural  war-made  depressions.  Very  pos- 
sibly, therefore,  this  result  (running  to  the  effect  that  the 
cyclothymic  forms  of  mental  disease  are  rare  in  military  life) 
may  need  revision. 

72.  Summary  of  general  considerations  concerning  the 
nature  of  the  Shell-shock  neuroses  (paragraphs  40-71). 

Having  (a)  roughly  delimited  the  Shell-shock  neuroses 
from  syphilis,  epilepsy,  and  somatic  disease,  we  inquired 

{b)  What,  after  all,  are  functional  neuroses?  We  re- 
mained dissatisfied  with  a  definition  by  negatives.  But  we 
found  that 

(c)  practically  the  problem  seemed  to  reduce  to  telling  the 
organic  apart  from  the  functional  and  we  found  that 

(d)  in  almost  all  cases  we  have  to  raise  the  hypothesis 
of  the  organic.     Also  that 

(e)  the  absence  of  external  injury  is  no  guarantee  against 
the  existence  of  internal  injury.     Also  that 

(/)  cases  are  frequent  enough  in  which  organic  and  func- 
tional phenomena  are  combined.     Also  that 

(g)  essentially  functional  cases  may  be  peritraumatic  or 
metatraumatic  (in  the  sense  of  Charcot's  hysterotraumatism). 
But 

(h)  the  statistical  majority  of  cases  remains  essentially 
functional. 

(i)  We  then  looked  over  a  series  of  cases  developing  in- 
cidentally in  the  war  and 

(j)  we  compared  these  with  the  war  cases,  the  latter 
arranged  cephalad. 


868 


TREATMENT   AND    RESULTS 


DIAGNOSTIC   ALLIANCES    OF   THE   SHELL- 
SHOCK   NEUROSES 


SCHIZOPHRENIA 
CYCLOTHYMIA 
MORONITY 
ALCOHOU5W 


SHELL 
SHOCK 

NEUROSES 


NEUROSYPHILIS 

EPILEPSY 

SOMATOPATHY 


Note  arrow  lengths:  Practically  we  find  shell-shock  neuroses  very  dif- 
ferent from  certain  functional  (or  but  mildly  organic)  disorders  and  not 
so  different  from  certain  seriously  organic  disorders. 


SCHIZOPHRENIA 
CYCLOTHYMUl 
MORONITY 
ALCOHOLISM 


SHELL 

SHOCK 

NEUROSES 


NEUROSYPHILIS 

EPILEPSY 

SOMATOPATHY 


Note  arrow  lengths:  TJieoretically,  shell-shock  neuroses,  being  presum- 
ably in  large  part  functional,  ought  to  ally  themselves  more  closely  with 
the  left-hand  group  than  with  the  right-hand  group.     But  they  do  not! 

In  short,  these  functional  diseases  are  not  so  hard  to  distinguish  from 
various  other  functional  diseases  as  they  are  from  certain  organic  diseases. 
The  most  serious  diagnostic  problem  is  between  the  war  neuroses  and 
organic  brain  disorders. 


Chart  17 


TREATMENT  AND  RESULTS 


869 


LOGICAL   PLACE    OF    THE   "REFLEX"   DISORDERS 
(OF   BABINSKI-FROMENT) 


e.^.  ncxirosyjdiilis  paretica 


ORGANO- 
PSYCHOPATHIC 


Hysteria  e.g. 


DYNAMO- 
PSYCHOPATHIC 


ORGANO - 
NEUROPATHIC 

/ 


DYNAMO - 
NEUROPATHIC 


Babinski's  "reflex**    \ 
e.^.  neurosyphilis  labetica      or  physiopathic  disorders  aV, 

A  frequent  error  of  neurologists  has  been  to  identify  "  functional  "  with 
"  psychic  "  when  it  came  to  a  question  of  the  classical  functional  neuroses. 
The  above  diagram  indicates  that  "  functional "  contains  more  than 
"psychic."  Doubtless  much  that  goes  under  the  name  "unconscious" 
belongs  in  the  right  lower  quadrant  of  this  diagram.  See  discussion  in 
text. 


Chart  18 


870  EPICRISIS 

{k)  We  found  many  war  cases  showing  emphasis,  reminis- 
cence, or  repetition  of  ante-bellum  phenomena  (weak  spots, 
locus  minoris  resistentiae,  imitation),  but 

(/)  we  also  found  that  perfectly  sound  untainted  men  could 
succvunb  to  Shell-shock  neurosis. 

{m)  We  found  a  few  purely  psychogenic  cases  without 
sign  or  suspicion  of  physical  shock. 

{71)  We  studied  the  localization  (traumatotropic)  group. 

{0)  We  arrived,  with  the  aid  of  Babinski,  at  the  necessity 
of  splitting  fimctional  cases  into  psychopathic  and  physio- 
pathic. 

73.  Summary  of  general  considerations :  continued. 

We  found  ourselves  looking  on  the  Shell-shock  neuroses  as, 
like  other  functional  neuroses,  in  a  sense  mental  diseases. 
Perhaps  we  would  better  say  (to  get  rid  of  all  suspicion  of 
medicolegal  "  insanity  ")  that  the  Shell-shock  neuroses  seemed 
to  us  In  some  sense  psychopathic.  But,  though  the  Shell- 
shock  neuroses  looked  psychopathic  and  were  presumably 
more  functional  than  organic  in  nature,  It  was  a  curious  thing 
that,  practically  speaking,  the  Shell-shock  neuroses  proved  to 
be  farther  away  from  the  more  functional  of  the  psychoses 
than  from  certain  organic  psychosis. 

In  particular,  we  found  reliable  authors  Insisting  on  the 
practical  diagnostic  necessity  of  excluding  syphilis,  epilepsy, 
somatic  disease  —  whereas  the  nature  and  causes  of  the  Shell- 
shock  neurosis  seemed  theoretically  to  withdraw  them  most 
remotely  from  that  triad  of  mainly  organic  disorders.  By  the 
same  token,  theoretically  one  might  have  supposed  these 
Shell-shock  neuroses  to  draw  very  near  to  those  far  less 
organic  disorders  (schizophrenia,  cyclothymia,  feeble-mlnded- 
ness  {i.e.,  the  slighter  degrees  likely  to  be  found  In  military 
service,  alcoholism)  —  yet  practically  few  large  diagnostic 
problems  came  to  light  as  between  the  Shell-shock  neuroses 
and  the  tetrad  of  dynamic  or  lightly  organic  diseases  above 
listed, 

74.  Diagrammatlcally  this  situation  Is  presented  in 
Chart  17- 

But  why  should  the  Shell-shock  neuroses  seem  so  "  or- 
ganic"?    Partly,  it  is  probable,  because  the  term  "  organic  " 


EPICRISIS  871 

is  too  often  used  to  mean  "  subcortical."  In  another  dia- 
gram the  truer  relations  are  depicted,  with  four  classes  of 
phenomena  (Chart  18). 

(a)  Organic  mental  (cortical),  e.g.,  general  paresis. 

(b)  Functional  mental  (cortical),  e.g.,  hysteria. 

(c)  Organic  neural  (subcortical),  e.g.,  tabes  dorsalis. 

(d)  Functional  neural  (subcortical),  e.g.,  "reflex"  disorders. 

Diagnostic  Differentiation  Problem 

75.  Having  disposed  of  the  problem  of  the  rougher  De- 
limitation of  the  Shell-shock  neuroses,  we  approach  the 
problem  of  their  finer  Differentiation.  For  the  sake  of 
the  present  argument  we  propose  to  regard  the  Shell-shock 
neuroses  as  essentially  Dynamopathic,  i.e.,  functional 
whether  in  the  ordinary  mind-bom  (psychogenic)  sense  of 
classical  hysteria  or  in  the  modem  nerve-bom  (neurogenic) 
sense  of  Babinski.  The  problem  of  this  differentiation  will 
accordingly  be  that  between  the  dynamopathic  and  the 
organopathic. 

In  the  orderly  diagnosis  of  mental  disease,  from  the  stand- 
point of  the  major  orders  or  groups,  we  ordinarily  come  at 
this  point  to  the  focal  brain  diseases.  In  analyzing  the  neuro- 
psychiatric  problem  of  a  so-called  Shell-shocker,  it  is,  of 
course,  our  bounden  duty  to  exclude  syphilis.  Even  though 
the  percentage  of  syphilitic  victims  of  Shell-shock  is  not  high, 
yet  these  cases  promise  so  much  from  treatment  that  they 
deserve  to  get  their  diagnosis  as  early  as  possible,  and  the 
English  workers  who  have  worked  most  in  the  syphilitic 
field  insist  upon  this  point. 

We  next  proceed,  as  above  indicated,  to  the  elimination  of 
hypophrenia  with  all  the  various  grades  of  feeble-minded- 
ness.  Thirdly,  we  try  to  exclude  the  various  forms  of  epi- 
lepsy; and  fourthly,  the  effects  of  alcohol,  drugs  and  poisons. 

In  ordinary  civilian  practice,  such  as  that  at  the  Psycho- 
pathic Hospital,  the  orderly  elimination  for  diagnostic  pur- 
poses of  the  great  groups  of  the  syphilitic,  hypophrenic 
(feeble-minded),  epileptic  and  alcoholic,  leaves  us  with  cases 
in  which  there  either  is  or  is  not  important  evidence  of  or- 


872  EPICRISIS 

ganic  nervous-system  disease,  such  as  that  shown  In  cases 
with  heightened  intracranial  pressure  or  in  cases  with  asym- 
metry of  reflexes  and  other  forms  of  parareflexia.  In  miU- 
tary  practice  these  logical  questions  of  prior  elimination  of 
syphilis,  feeble-mindedness,  epilepsy,  and  alcoholism  must  go 
a-glimmering  at  first,  unless  their  signs  are  so  obvious  as  to 
permit  diagnosis  by  inspection. 

76.  But  the  nervous  and  mental  cases  almost  one  and  all 
give  rise  to  the  suspicion  at  least  of  organic  disease,  possibly 
traumatic  in  origin.  Even  when  a  man  falls  to  the  ground 
without  a  scratch  upon  his  skin,  there  is  some  question 
whether  in  his  fall  he  has  not  sustained  some  slight  intra- 
cranial hemorrhage  which  the  lumbar  puncture  fluid  might 
show.  Add  to  this  that  the  signs  of  hysteria  are  very  often 
unilateral,  and  it  will  readily  be  conceived  how  much  like  an 
organic  case  an  hysteric  in  the  casualty  clearing  station  may 
look.  Rapid  decision  may  be  necessary  in  order  to  get  im- 
mediate effects  in  psychotherapy  a  few  minutes  or  hours  after 
the  shell  explosion,  and  one  may  need  to  choose  between 
applying  a  possibly  unsuccessful  psychotherapy  forthwith  and 
making  a  thorough  neurological  examination.  As  Babinski 
has  pointed  out,  making  a  thorough  neurological  examination 
gives  opportunity  for  all  sorts  of  medical  suggestion  to  be 
conveyed  to  the  patient.  It  would  appear  that  many  an 
hysterical  anesthesia  has  been  given  to  a  patient  by  the  very 
suggestion  of  the  physician  testing  sensation.  Here  one  does 
not  refer  to  malingering  in  the  conscious  and  designed  sense 
of  the  term,  but  to  the  operation  of  some  genuinely  psycho- 
pathic, that  is  to  say,  hysterical  process. 

77.  In  the  case  of  head  injury,  naturally  the  majority  of 
nerve  phenomena  will  ordinarily  be  upon  the  opposite  side 
of  the  body  to  the  side  of  the  head  that  is  injured.  The 
reverse  situation  holds  for  hysterical  cases,  wherein  it  would 
appear  that  the  bursting  of  a  shell,  let  us  say  upon  the  left 
side  of  the  body,  seems  to  determine  contractures,  paralyses 
and  anesthesias  to  that  same  left  side  of  the  body;  now  and 
then  complicated  cases  appear  which  put  the  neurologist 
through  his  best  paces.  Such  a  case  is  that  of  a  man  who  was 
wounded  on  the  left  side  of  the  head  and  promptly  developed 


EPICRISIS  873 

a  hemiplegia  on  the  same  (left)  side,  with  aphasia.  Now 
aphasia  ought  to  be  the  result  of  a  lesion  on  the  left  side  of 
the  brain  in  the  common  run  of  cases,  whereas  left-sided  hemi- 
plegia ought  to  be  the  result  of  lesion  on  the  right  side  of  the 
brain.  In  point  of  fact,  the  analyst  of  this  case  felt  that  he 
was  dealing  with  a  direct  injury  on  the  left  side  of  the  brain, 
leading  to  aphasia,  and  a  lesion  by  contrecoup  on  the  right 
side  of  the  brain,  leading  to  a  left-sided  hemiplegia. 

It  is  not  only  at  the  casualty  clearing  stations  and  along 
the  lines  of  communication  that  the  difficulties  in  telling 
Shell-shock  in  the  neurotic  sense  from  traumatic  psychosis 
and  the  effects  of  focal  brain  lesions  are  found,  since  the  lit- 
erature amply  shows  that  diagnostic  problems  remain  open  for 
weeks  or  months  in  the  various  institutions  of  the  interior, 
to  which  all  the  belligerents  have  been  forced  to  send  their 
cases. 

78.  A  glance  at  the  differential  tables  that  have  been  de- 
veloped, for  example,  by  the  French  neurologists,  will  show 
how  fine  the  diagnosis  betwixt  a  hysterical  and  an  organic 
disease  may  be,  especially  when  we  consider  how  often  there 
are  admixtures  of  the  two.  The  rule  holds  for  the  vast  ma- 
jority of  cases  that  absolute  bullet  wounds  or  shrapnel 
wounds  do  not  produce  Shell-shock;  and  the  statistical  story 
is  so  clear  that  one  might  almost  think  of  the  wounds  as  in 
some  sense  protective  against  shock,  that  is,  gainst  Shell- 
shock,  not  against  traumatic  or  surgical  shock.  Neverthe- 
less, by  some  process  whose  nature  Is  obscure,  the  hysteric  Is 
apt  to  pick  up  some  slight  wound  and,  as  it  were,  surround 
this  wound  with  hysterical  anesthesia,  hyperesthesia,  paraly- 
sis or  contractures. 

The  chances  are,  if  we  should  collect  all  our  civilian  cases 
of  Railway  Spine  and  of  Industrial  accident  with  traumatic 
neuroses,  we  should  be  able  to  prove  this  same  strange  rela- 
tion between  slight  wound  in  a  particular  part  of  the  body 
and  the  local  determination  of  hysterical  symptoms  to  that 
region.  Of  course,  the  determination  follows  no  known  laws 
of  nerve  distribution  to  skin  or  muscles,  and  the  effect  is 
apparently  a  psychopathic  or,  at  all  events,  a  dynamic  proc- 
ess without  clear  relations  to  the  accepted  landmarks. 


874  EPiCRisis 

I  do  not  mean  to  suggest,  that  aside  from  the  hurry  of  war, 
the  differential  diagnoses  here  are  more  difficult  than  those 
in  civilian  practice;  but  the  difficulties  are  at  least  as  great 
as  those  that  have  faced  the  civilian  practitioner.  What 
needs  emphasis  is  that  just  because  we  have  concluded  that 
the  statistical  majority  of  the  cases  of  so-called  Shell-shock 
belongs  in  the  division  of  the  neuroses,  we  should  not  feel 
too  cock-sure  that  a  given  case  of  alleged  Shell-shock  appearing 
in  the  war  zone  or  behind  it  is  necessarily  a  case  of  neurosis. 
After  the  early  "  period  of  election  "  for  psychotherapy 
in  the  war  zone  has  passed,  there  can  be  no  excuse  except 
general  war  conditions  for  not  according  to  every  case  of 
alleged  Shell-shock  a  complete  neuropsychiatric  examination, 
having  due  regard  to  the  ideas  of  Babinski  concerning  medical 
suggestion  of  new  increments  and  appendices  to  the  original 
hysteria,  developed  in  battle  or  shortly  thereafter. 

We  have,  however,  been  able  to  find  in  the  literature  good 
instances  of  puzzling  diagnosis  in  which  such  conditions  are 
in  evidence  as  acute  meningitis  of  various  forms,  hydrophobia, 
tetanus,  and  the  like. 

Especially  in  the  diagnosis  against  Shell-shock  hysterias 
we  may  need  to  think  of  the  abnormal  forms  of  tetanus,  to 
which  an  entire  book  in  the  Collection  Horizon  has  been  de- 
voted. The  differential  diagnostic  tables  here  draw  up  dis- 
tinctions between  local  tetanus,  involving,  let  us  say,  the  con- 
tracture of  one  arm,  as  against  a  hysterical  monoplegia. 

79.  The  focal  brain  group  of  psychoses  here  termed  en- 
cephalnpsychoses,  is  illustrated  by  a  comparatively  short 
series  of  cases,  16  in  number  (Cases  103-117).  Many  more 
cases  of  this  group  are  presented  in  Section  B,  On  the  Nature 
and  Causes  of  Shell-shock.  The  motive  here  Is  to  show 
sundry  effects  of  focal  brain  lesions  produced  in  the  war  and 
not  related  with  shell-shock.  Case  103  was  the  curious  case 
(see  above)  of  aphasia  with  hemiplegia  —  not  upon  the  right 
side,  but  upon  the  left  side.  There  had  been  a  wound  in 
the  left  parietal  region,  and  the  aphasia  was  presumably  con- 
sequent upon  a  direct  affection  of  the  left  hemisphere.  On 
the  other  hand,  the  left-sided  hemiplegia  may  probably  be 
regarded  as  due  to  lesions  on  the  right  side  of  the  brain  pro- 


EPICRISIS  875 

duced  by  contrecoup.  The  case  not  only  has  surgical  im- 
plications and  suggestions  of  importance,  but  also  it  throws 
some  light  on  the  possibilities  in  concussion  of  minor  degree. 
As  the  cases  in  Section  B  (On  the  Nature  and  Causes  ot  Shell- 
shock)  show,  shell-shock,  the  physical  factor,  is  apt  to  pro- 
duce anesthesia  and  paralysis  or  contracture  on  the  side  ex- 
posed to  the  shell-shock.  The  means  by  which  these  symp- 
toms ipsilateral  with  the  shock  are  produced  is  commonly 
thought  to  be  the  "  hysterical  mechanism,"  whatever  that 
may  be.  Lhermitte,  however,  suggests  that  in  some  cases 
such  phenomena  might  be  due  to  an  actual  brain  jarring  with 
contrecoup  effects.  However,  it  must  be  granted  that  Case 
103  did  not  come  to  autopsy. 

80.  Case  104  might  perhaps  better  be  considered  in  the 
section  on  alcoholism,  since  a  gun-shot  wound  of  the  head 
may  be  regarded  as  having  produced  intolerance  of  alcohol 
in  the  classical  manner,  similar  to  that  described  in  Case 
97,  wherein,  however,  the  trauma  was  ante-bellum.  Pe- 
culiar crises  associated  with  cortical  blindness,  vertigo,  and 
hallucinations,  characterized  a  case  of  brain  trauma  by  bullet 
(Case  105).  Case  106  is  that  of  a  Tunisian,  who  before  the 
war  had  had  a  number  of  theopathic  traits  with  mystical 
hallucinations,  but  after  a  gun-shot  wound  of  the  occiput 
developed  lilliputian  hallucinations  and  micromegalopsia. 

81.  Cases  107-112  are  cases  of  infection  or  probable  in- 
fection. Cases  107  and  108  are  instances  of  meningococcus 
meningitis,  the  second  of  which  appears  to  have  followed 
shell-shock  (?).  Case  107  led  to  psychosis  with  dementia. 
Case  109  developed  a  meningitic  syndrome,  which  followed 
shell  explosion  a  metre  away,  the  syndrome  lasting  14  months. 
The  spinal  puncture  fluid  was  several  times  found  to  contain 
blood.  There  was  apparently  no  infection  of  the  fluid  as  in 
Case  112.  Possibly  Case  109  should  be  set  down  as  an  un- 
usual example  of  shell-shock  psychosis,  chiefly  dependent 
upon  meningeal  hemorrhage. 

82.  A  syphilitic  (Case  no)  in  which  appropriate  tests  were 
made  and  found  positive,  showed  at  autopsy  a  yellowish 
abscess  or  area  of  softening  in  the  right  hemisphere.  The 
curious  point  about  this  case  was  that  the  only  neurological 


876  EPICRISIS 

phenomenon  in  the  case  was  the  absence  of  knee-jerks  in  the 
early  part  of  the  day;  later  in  the  day,  they  would  appear 
once  more.  Possibly  Case  1 1 1 ,  a  case  of  somewhat  doubtful 
nature  but  presumably  of  organic  hemiplegia,  ought  to  be 
aligned  more  with  the  group  of  cases  illustrating  the  nature 
and  causes  of  Shell-shock.  The  case  was  not  one  with  the 
physical  factor  shell-shock,  since  the  phenomena  began  ten 
days  after  a  serene  convalescence  following  an  operation  for 
chronic  appendicitis.  Perhaps  the  case  was  one  of  organic 
lesion  grafted  upon  a  neurosis. 

83.  Case  112  is  the  one  noted  above  of  infection  of  the 
spinal  fluid.  It  is  the  only  case  of  infected  meningeal  hemor- 
rhage observed  by  Guillain  and  Barre  in  a  wide  experience. 
As  a  rule,  these  hemorrhages  remain  aseptic  and  have  a 
favorable  prognosis.  The  organism  cultivated  from  the  spinal 
fluid  proved  to  be  the  pneumococcus.  Case  113  yielded  a 
somewhat  remarkable  phenomenon  and  perhaps  would  be 
more  logically  considered  in  relation  with  the  series  of  cases 
in  Section  B  that  show  the  picking  up  of  ante-bellum  weak 
spots  (Cases  287-301);  for  this  subject  had  had  two  serious 
affections  of  the  brain  ante-bellum.  He  had  had  a  poli- 
myelitis  at  five,  affecting  the  left  leg,  and  he  had  had  a  right 
hemiplegia  with  aphasia  following  pneumonia,  at  20.  He 
was  struck,  (but  apparently  not  wounded)  by  shrapnel  on  the 
right  shoulder,  and  developed  athetotic  movements  of  the 
right  hand,  as  well  as  a  general  weakness  of  the  left  leg.  In 
this  case,  according  to  Batten,  the  stress  had  been  sufficient 
to  bring  into  prominence  symptoms  due  to  an  old  cerebral 
lesion.  Whether  the  mechanism  in  this  case  is  hysterical  is 
doubtful. 

84.  That  not  every  case  of  hemianesthesia  is  hysterical  is 
suggested  by  Case  114,  in  which  the  diagnosis  of  hysteria 
was  actually  made;  but  the  diagnosis  was  soon  rendered 
doubtful  by  the  fact  that  there  was  no  evidence  of  autosug- 
gestion or  heterosuggestion.  Other  phenomena  make  a 
diagnosis  of  thalamic  hemianesthesia  more  likely. 

85.  Although  Shell-shock  is  not  the  subject  of  this  section, 
yet  a  case  of  syndrome  strongly  suggesting  multiple  sclerosis 
is   here    inserted,    following    shell-shock    (Case   115).     The 


EPICRISIS 


877 


co-existence  of  hysterical  and  organic  symptoms  is  illus- 
trated in  Case  116,  one  of  mine  explosion,  and  Case  117,  one 
of  injury  to  back.  Case  116  somewhat  resembled  another 
case  of  Smyly  (Case  219). 

86.   Differential  Diagnosis  between  Organic  and  Hysteric 
Hemiplegia.     Babinski,  1900. 


Organic  Hemiplegia 
Paralysis  unilateral. 


2.  Paralysis  not  symptomatic,  e.g., 
in  unilateral  facial  paresis,  the 
paresis  occurs  also  when  bilateral 
synergic  movements  are  being  per- 
formed. 


3.  Paralysis  affects  voluntary,  con- 
scious, and  unconscious  or  sub-con- 
scious movements;  hence,  (a)  pla- 
tysma  sign,*  (6)  sign  of  combined 
flexion  of  thigh  and  trunk,  and 
(c)  absance  of  active  balancing  arm 
movements  in  walking  contrasted 
with  exaggeration  of  passive  bal- 
ancing movements  (limb  inert  on 
sudden  turn  of  body). 

4.  Tongue  usually  slightly  deviated 
to  the  paralyzed  side. 

5.  Hypertonicity  of  muscles,  espe- 
cially at  first.  The  buccal  com- 
missure may  be  lowered,  the  eye- 
brow lowered;  there  may  be  exag- 
gerated flexion  of  the  forearm,  and 
the  sign  of  pronation  may  occur 
(hand  left  to  itself  lies  in  pronation). 

6.  Tendon  and  bone  reflexes  often 
disturbed  at  the  beginning,  either 
absent,  weakened,  or  exaggerated 
(almost  always  exaggerated.)  In 
many  cases,  there  is  epileptoid  trepi- 
dation of  the  foot. 


Hysterical  Hemiplegia 

1.  Paralysis  not  always  unilateral; 
especially  facial  paralysis,  usually 
bilateral. 

2.  Paralysis  sometimes  symptomatic; 
facial  paralysis  almost  always  symp- 
tomatic. With  complete  unilateral 
paralysis,  the  muscles  of  the  para- 
lyzed side  may  function  normally 
during  the  performance  of  bilateral 
synergic  movements. 

3.  Voluntary,  unconscious,  or  sub- 
conscious movements  not  disordered. 
Absence  of  platysma  sign  and  com- 
bined flexion  of  thigh  and  trunk. 
The  active  balance  movements  of 
arm  may  be  lacking  but  there  is  no 
exaggeration  of  passive  balance 
movements. 


4.  Tongue  sometimes  slightly  devi- 
ated to  the  paralyzed  side;  but 
sometimes  contralateral  deviation. 

5.  No  hypertonicity  of  muscles.  If 
facial  asymmetry  exists,  it  is  due 
to  spasm.  No  exaggerated  flexion 
of  forearm,  and  no  pronation  sign. 


6.  No  alteration  of  tendon  or  bone 
reflexes.  No  trepidation  of  the 
foot. 


*  More  energetic  contraction  of  platysma  on  healthy  side  when   mouth  is 
opened  or  when  head  is  flexed  against  resistance. 


878 


EPICRISIS 


.  Skin  reflexes  usually  disordered. 
Abdominal  and  cremasteric  reflexes, 
especially  at  first,  weakened  or 
abolished.  On  stimulation  of  sole, 
toes,  and  especially  the  great  toe, 
are  extended  on  the  metatarsals. 
Babinski  toe  reflex.  Extension  of 
great  toe  often  associated  with 
abduction  of  other  toes  (fan  sign). 
Sometimes  exaggeration  of  reflexes 
of  defence. 

Contracture  characteristic  and  non- 
reproducible  by  voluntary  contrac- 
tions. The  hand-grip  yields  a  sen- 
sation of  elastic  resistance,  auto- 
matically accentuated  on  passive 
extension  of  the  hand. 

Evolution  of  diseased  regular  con- 
tracture follows  flaccidity.  When 
regression  of  disorder  occurs,  it  is 
progressive. 

Paralysis  not  subject  to  ups  and 
downs  (motor  defect  fixed). 


7.  No  disturbance  of  skin  reflexes. 
Abdominal  and  cremasteric  reflexes 
normal.  Babinski  toe  reflex  and  fan 
sign  absent.  Defense  reflexes  not 
exaggerated. 


The  contracture  can  be  reproduced 
by  voluntary  contractions. 


Evolution  of  disease  capricious. 
Paralysis  may  remain  indefinitely 
flaccid  or  may  be  spastic  from  the 
beginning.  Spastic  phenomena  may 
sometimes  be  associated  (particu- 
larly in  the  face)  with  characteris- 
tic phenomena. 

The  disorder  may  get  better  and 
worse  alternately  several  times,  alter 
rapidly  in  intensity,  and  present 
transitory  remissions  which  may 
last  even  but  a  few  moments  (mo- 
tor defect  variable). 


87.  Differential  between  Reflex  (Physiopathic)  Contrac- 
ture and  Paralysis,  and  Hysterical  Contracture  and  Paralysis. 
Babinski,  191 7. 


Reflex 
Paralysis  usually  limited  but  severe 
and  obstinate  even  when  methodi- 
cally treated. 

In   the   hypertonic   forms   attitude 
of  the  limb  does  not  correspond  to 
any  natural  attitude. 
.    Amyotrophy  marked  and  of  rapid 
development. 


Vasomotor  and  thermic  disorder 
often  very  marked,  accompanied  by 
an  often  very  pronounced  reduction 
in  amplitude  of  oscillations  measured 
by  oscillometer. 


Hysterical 

1.  Paralysis  usually  extensive  but 
superficial  and  transient  if  treated. 

2.  The  hysterical  contracture  as  a 
rule  resembles  a  natural  attitude 
fixed. 

3.  Amyotrophy,  as  a  rule,  absent, 
even  when  the  paralysis  is  of  long 
standing.  If  existent,  it  is  not 
marked. 

4.  There  may  be  thermo-asymmetry 
but  it  is  slight.  There  are  no  very 
characteristic  vasomotor  disorders 
nor  modifications  in  amplitude  of 
oscillations. 


EPICRISIS  879 

5.  Sometimes    very    marked     hyper-      5.    No  sharply  defined  hyperidrosis. 
idrosis. 

6.  Tendon  reflexes  often  exaggerated.      6.   No    modifications    of    tendon    re- 

flexes. 

7.  Hypotonia    sometimes    very    well      7.   Hypotonia  absent, 
marked,  and  in  arm  paralysis  main 

ballante. 

8.  Mechanical     over     excitability     of      8.   Over-excitability  of  muscles  absent. 
muscles,  often  accompanied  by  slow 

response  (?). 

9.  Fibrotendinous  retractions  of  rapid      9.    No  retractions  even  if  paralysis  is 
development  except  in  the  rare  com-  of  long  duration. 

pletely  flaccid  forms. 

10.  Trophic    disorders    of    bone,    de-       10.    No  trophic  disorders, 
calcification  of  the  hairs  and  of  the 

phaneres. 


88.  The  section  on  Shell-shock  diagnosis  contains  102 
cases  (Cases  371-472).  These  cases  differ  in  no  respect  from 
those  of  Section  B  except  that  many  of  them  are  more  puzz- 
ling and  dubious  and  have  been  presented  by  their  reporters 
more  from  the  standpoint  of  diagnosis  than  from  that  of 
etiolog>'  or  therapeutics.  In  general  arrangement,  the  cases 
roughly  correspond  to  those  of  Section  B.  First  are  four 
cases  illustrating  the  value  of  lumbar  puncture  data  (Cases 
371-374),  There  follow  cases  with  either  a  mixture  of  or- 
ganic and  functional  symptoms,  or  such  a  constellation  of 
symptoms  as  might  readily  lead  to  erroneous  diagnosis 
(Cases  375-381).  Retention  and  incontinence  of  urine  after 
shell-shock  are  illustrated  in  Cases  382-384.  Crural  mono- 
plegia, monocontractures,  and  other  affections  of  one  leg 
are  shown  in  Cases  385-392 ;  but  these  monocrural  cases  are 
in  many  respects  peculiar  or  even  unique  as  compared  with 
the  monocrural  cases  of  Section  B.  Peculiar  paraplegias  or 
spasms  affecting  both  legs  are  found  in  the  series  393-395. 
Then  follow  (Cases  396-400)  other  cases  of  doubtful  spinal 
cord  lesion  or  shock,  including  several  with  dysbasia.  Camp- 
tocormia,  astasia-abasia  and  abdominothoracic  contracture 
are  found  respectively  in  401,  402,  and  403.  Affections  of 
one  arm  follow  (Cases  404-409) .  An  assortment  of  peculiar 
cases   in    which   the    differentiation    between   hysteria   and 


880  EPICRISIS 

structural  disease  is  in  question,  is  found  in  Cases  410-415. 
Peripheral  nerve  injuries  of  a  sort  which  might  be  confused 
with  Shell-shock  phenomena,  including  one  of  light  tetanus, 
are  considered  in  Cases  416-419.  A  variety  of  cases  bearing 
upon  the  question  of  the  reflex  or  physiopathic  disorders  of 
BabinsM  is  found  in  the  series  of  Cases  420-432.  Peculiar 
eye  phenomena  are  presented  by  Cases  433-438;  and  cases 
of  otological  interest  are  439  and  440.  Epileptoid,  obsessive, 
fugue,  and  amnestic  phenomena  follow  in  Cases  441-450; 
451  and  452  are  cases  of  soldier's  heart.  The  simulation 
question  is  presented  in  a  series  of  20  cases  (Cases  453-472). 


General  Nature  of  Shell-shock 

89.  We  are  now  ready  to  consider  in  how  far  Shell-shock  * 
is  a  distinctive  disease.  The  physical  event,  shell-shock*  we 
have  seen  at  work  in  most  of  the  major  groups  of  mental 
disease  and  in  some  groups  of  nerv^ous  disease.  Shell-shock, 
the  physical  event,  has  started  up  a  "Shell-shock"  paresis, 
a  "Shell-shock"  epilepsy,  a  "Shell-shock"  Graves'  disease, 
a  "  Shell-shock  "  dementia  praecox,  wherein  the  term  "  Shell- 
shock  "  is  merely  a  more  specific  term  than  the  term 
"  traumatic."  The  physical  event,  shell-shock,  has  in  special 
ways  also  changed  the  responses  of  the  feeble-minded,  the 
alcoholic,  the  cyclothymic,  and  the  psychopathic  person  of 
whatever  111 -defined  sort  may  get  into  military  service. 

The  physical  event,  shell-shock,  has  likewise  caused  focal 
irritative  and  destructive  brain  disease,  spinal  cord  disease, 
peripheral  nerve  disease;  and  many  well-recognized  species 
of  the  so-called  "  organic  "  diseases  of  the  nerv^ous  system 
have  been  produced.  Shell-shock  "  organic  "  diseases  have 
proved  as  difficult  to  tell  from  all  sorts  of  Shell-shock  "  func- 
tional "  diseases  as  ever  have  been  the  organic  and  functional 
analogues  of  these  diseases  in  peace  practice. 

*  I  capitalize  Shell-shock  here  (as  elsewhere)  to  indicate 
the  name  of  a  supposed  disease  entity  and  leave  shell-shock 
without  an  initial  capital  to  indicate  the  physical  event. 


EPICRISIS  88 1 

But,  besides  (a)  sharing  in  the  cause  of  mental  and  nervous 

disease  (in  the  sense  of  "  Shell-shock  "  general  paresis  and 
"Shell-shock  "  tabes,  wherein  at  least  one  other  factor,  viz. 
the  spirochete,  is  known  to  be  at  work)  and  (b)  producing 
mental  and  nervous  disease  by  killing  or  weakening  or  sensi- 
tizing neurones  in  the  classical  manner  of  the  "  focal  "  lesion, 
the  physical  event,  Shell-shock,  (c)  appears  able  to  bring  out 
the  subtler  diseases  and  dispositions  of  mind  which  we  term 
psychoneuroses,  that  is,  hysteria,  neurasthenia,  psychasthenia. 
Just  as  we  have  for  years  spoken  of  "  traumatic  "  psychoneu- 
roses, so  we  may  now  speak  of  "  Shell-shock  "  psychoneuroses 

—  nor  should  anyone  believe  we  cheat  ourselves  with  the 
idea  that  the  adjective  "Shell-shock"  has  helped  us  more  re 
genesis  than  the  adjective  "  traumatic."  "  Shell-shock  hy- 
steria "  and  "  traumatic  hysteria  "  are  on  precisely  the  same 

—  slippery  —  footing  in  the  matter  of  their  origin.  The 
physics  and  chemistry  of  the  psychoneuroses  remain  in  Egyp- 
tian darkness. 

The  physical  event,  shell-shock,  then,  as  the  common  man 
might  say,  affects  body,  brain,  and  mind  in  a  great  number  of 
familiar  ways;  and  these  familiar  ways  remain  as  plain  or 
as  blind  as  the  neuropathology  and  the  psychopathology  of 
today  leave  them.  If  thunderstorms  and  earthquakes  got 
suddenly  more  frequent,  we  should  have  numbers  of  "  light- 
ning neuroses  "  and  "  earthquake  hysterias,"  neither  of 
which  would  render  the  physics  and  chemistry  of  the  psycho- 
neuroses immediately  a  whit  clearer. 

When  the  common  man  speaks  of  some  one  as  suffering 
from  lightning  stroke  or  earthquake,  he  is  entitled  to  be  met 
halfway  by  his  hearer,  who  readily  understands  that  the 
victim  is  suffering  some  sort  of  transient  or  permanent  effects 
of  the  stroke  or  quake.  In  a  like  common  sense  should  the 
term  shell-shock  be  taken.  Stroke,  quake,  or  shock,  each 
physical  event  is  recognized  as  a  factor  in  the  situation.  An 
event  has  become  a  factor.  A  condition  for  which  the  noun 
"  shell-shock  "  was  descriptive,  in  the  present  tense  of  some 
event,  has  passed  into  history;  and  the  adjective  "  shell- 
shock  "  is  now  explanatory  of  the  past  cause,  or  one  of  the 
past  causes,  of  a  new  situation.     Shell-shock,  the  physical 


882  EPICRISIS 

event,  takes  part  in  a  great  number  of  pathological  events 
and  as  such  lapses  from  noun  to  adjective. 

But  what  are  these  pathological  events,  viz.,  the  conditions 
of  disease,  that  supervene?  So  far,  in  our  consideration  ot 
psychoses  incidental  in  the  war,  we  have  found  Shell-shock 
varieties,  perhaps,  of  mental  disease;  again,  possibly  a  few 
Shell-shock  species,  using  both  these  terms,  variety  and 
species,  in  a  quasi  botanical  or  zoological  sense.  But  in 
either  instance  we  do  not  rise,  under  the  ordinary  principles 
of  nomenclature,  beyond  the  adjective:  Is  there  any  evidence 
that  shell-shock,  the  physical  happening,  has  issued  in  a 
pathological  event  of  greater  dignity,  namely,  a  genus  of 
disease?  Can  shell-shock  rise  to  the  dignity  of  a  proper 
noun.  Shell-shock,  so  that  we  might  think  of  e.g.,  a  new  genus 
of  the  psychoneuroses,  something  coordinate  with  hysteria, 
neurasthenia,  psychasthenia?  None,  I  believe,  has  the 
hardihood  to  propose  a  new  genus  of  mental  or  nervous 
disease  for  Shell-shock  regarded  as  a  pathological  event. 
A  fortiori,  it  is  unheard-of  to  think  of  Shell-shock,  the  patho- 
logical event,  as  representing  a  new  order  of  such  events, 
coordinate  with  the  psychoneuroses  or  the  epilepsies,  for 
example. 

Shell-shock,  the  pathological  event,  we  conclude,  is  a  variety 
or  a  species,  hardly  a  genus  or  an  order  of  mental  or  nervous 
diseases.  If  we  can  keep  in  mind  the  obvious  distinction 
between  shell-shock,  the  physical  event,  and  Shell-shock,  the 
pathological  event,  we  shall  save  ourselves  much  trouble. 
And  if  we  can  apply  the  ordinary  criteria  for  the  differentiation 
of  the  great  groups  (or  orders)  and  the  lesser  groups  (or  genera) 
of  mental  and  nervous  disease  to  the  given  concrete  case,  we 
shall  not  go  far  wrong  therapeutically  in  any  case  of  so- 
called  Shell-shock.  For  Shell-shock,  the  pathological  event, 
becomes  a  humble  variety  or  species  of  disease  whose  thera- 
peutic indications  are  in  larger  part  those  of  higher  and  com- 
paratively well-recognized  genera  of  disease,  e.g.,  hysteria, 
neurasthenia,  psychasthenia. 

A  shock  is  not  a  smash,  a  crush,  a  breach.  A  shock  liter- 
ally shakes.  The  shaken  thing  stays,  for  a  time  at  least. 
Shaken  up  or  down,  the  victim  of  shock  is  not  at  first  thought 


EPICRISIS  883 

of  as  done  for.  The  spirit  of  the  language  is  against  the 
thought  of  shock  as  destruction  or  even  as  permanent  irri- 
tation. Shock  ought  to  be  a  "  functional  "  rather  than  an 
"  organic  "  thing,  as  medicine  bandies  these  terms  about. 
Shell-shock  or  Surgical  Shock,  it  is  all  one  to  the  logic  of  shock, 
which  is  thought  of  as  a  physical  or  chemical  disturbance  of 
mechanisms  and  arrangements  that  are,  or  ought  to  be  re- 
adjustable.  The  one  character  which  the  late  Professor  Royce 
told  me  (in  conversation)  he  could  find  in  the  term  "  func- 
tional "  was  the  idea  "  reversible."  Shock  is  or  ought  to  be, 
as  a  pathological  event,  reversible. 

If  this  thought  is  in  the  backs  of  our  minds  as  we  think  of 
Shell-shock,  it  can  readily  be  seen  why  the  "  organic,"  that  is, 
non-reversible  diseases,  do  not  take  kindly  to  the  term  Shell- 
shock.  Shell-shock,  the  pathological  event,  prefers  to  be  an 
item  in  the  pathology  of  function.  Can  we  further  specify? 
The  pathology  of  function,  neuropsychically  taken,  considers 
such  great  groups  as  the  psychoneuroses ;  (so  far  as  we  know) 
the  cyclothymias;  some  of  the  symptomatic  psychoses; 
a  portion  of  the  alcohol  and  drug  group;  some  of  the  epilep- 
sies; perhaps  the  dementia  prsecox  group;  not  to  mention 
various  unresolved  psychopathias.  The  psychoneuroses  are 
the  group  most  innocent  of  every  "  organic  "  taint:  the 
machinery  is  assumed  to  be  most  normal  in  them  and  pre- 
sumably the  effects  of  disorder  most  reversible. 

Shall  we  not  therefore  accept  the  psychoneuroses  as  the 
group  in  which  to  place  those  pathological  happenings  called 
Shell-shock?  It  will  do  no  harm  to  make  this  choice  if  we 
do  it  humbly  in  the  spirit  of  acknowledgment  that  we  know 
next  to  nothing  about  the  psychoneuroses.  The  psychoneu- 
roses should  fall  on  their  knees  to  Shell-shock  rather  than 
that  Shell-shock  make  obeisance  to  the  psychoneuroses.  For 
what  is  a  psychoneurosis?  It  is  a  functional  disease  of  the 
nervous  system  in  which  the  mind  plays  an  important  part  — 
it  is  also  probably  much  else.  But  the  "  much  else  "  is  as 
likely  to  be  found  in  Shell-shock  as  anywhere  else  during  these 
particular  years. 

Thus,  rehearsing  in  a  broad  way  the  case  arrangement  of 
Section  B,  we  find,  first,  autopsied  cases  and  cases  with  lum- 


884  EPiCRisis 

bar  puncture  data;  then  cases  with  prominent  admixture  of 
organic  phenomena;  a  few  cases  to  illustrate  the  victims'  own 
impressions  of  their  disease;  the  long  toe  to  top,  or  "  cepha- 
lad "  series  (crural  monoplegias  and  paraplegias,  campto- 
cormias,  astasia- abasias,  brachial  monoplegias,  brachial  para- 
plegias, deafmutism,  blindness) ;  the  series  to  illustrate  the 
idea  of  reflex  or  physiopathic  disorders;  the  series  of  delayed 
Shell-shock  phenomena;  the  series  to  show  the  picking  out 
by  Shell-shock  of  ante-bellum  weak  spots  and  tendencies  in 
the  organism;  cases  touching  the  hereditary  question;  pecu- 
liar and  unique  cases;  examples  of  Shell-shock  equivalents; 
and  cases  of  a  psychopathic  rather  than  local  hystero-trau- 
matic  trend. 

90.  At  the  outset  of  Section  B  (Shell-shock:  Nature  and 
Causes),  we  face  the  question  of  the  possibly  organic  nature 
of  Shell-shock.  It  is  safe  to  say  that  the  vast  majority  of 
cases  of  Shell-shock  do  not  die  of  Shell-shock,  and  the  col- 
lection of  material  from  true  Shell-shock  cases  that  are  killed 
by  accident  or  intercurrent  disease  has  proved  a  matter  of 
great  difficulty  under  military  conditions.  Of  course,  it  is 
possible  to  answer  the  question  d  priori,  by  agreeing  that 
any  case  with  structural  lesion  of  whatever  sort,  is  by  the 
same  token  not  a  case  of  Shell-shock. 

91.  Apparently  the  most  informatory  case  yet  presented  is 
that  of  Mott  (Case  197).  In  this  case,  death  came  in  24 
hours,  and  the  immediate  cause  of  death  was  doubtless  a 
small  hemorrhage  of  the  spinal  bulb.  There  was  a  congestion 
of  veins  in  the  bulb,  as  well  as  a  congestion  of  the  pia  mater 
over  all  other  parts  of  the  brain.  Nor  was  the  bulbar  hemor- 
rhage unique,  for  there  were  a  number  of  superficial  punctate 
hemorrhages.  In  short,  the  brain  was  not  even  grossly 
normal,  such  as  one  might  desire  in  a  case  of  true  Shell-shock 
as  conceived  by  a  priori  workers.  Yet,  according  to  Mott, 
there  are  microscopic  changes  of  an  intimate  nature  that  lie 
nearer  to  the  microscopic  possibilities  in  true  Shell-shock. 
For  example,  in  the  bulb  itself  there  was  a  distinct  and  photo- 
graphable  change  of  ner\-e  cells:  the  vago-accessorius  nucleus 
had  cells  in  a  state  of  chromatolysis.  The  internal  alterations 
of  these  cells,  with  dissolution  of  chromatic  material,  may 


EPICRISIS  885 

possibly  indeed  have  been  the  direct  cause  of  death  or  an 
indicator  of  its  direct  cause.  Here  again,  to  accord  full 
justice  to  Mott's  contention,  we  are  dealing  perhaps  more 
with  a  phenomenon  of  the  cause  of  death  than  with  a  Shell- 
shock  phenomenon.  According  to  Mott,  the  Shell-shock 
symptoms  themselves  are  due  to  capillary  anemia  and  to 
nerve  cell  changes  such  as  he  found  in  various  regions.  These 
nerve  cell  lesions  were  of  the  nature  of  chromatolysis  and 
identical  with  those  of  the  vago-accessorius  nucleus.  In  this 
connection,  one  thinks  of  the  ideas  of  Crile  concerning  ex- 
haustion and  its  effect  upon  certain  nerve  cells  and  other 
cells,  and  indeed  the  whole  conception  runs  back  to  the  early 
years  of  discussion  of  the  meaning  of  chromatin  deposits  in 
nerve  cells,  and  to  the  work  on  fatigue  of  such  cells.  It  may 
well  be  that  Mott's  suggestion  is  sound,  and  that  changes  of 
the  order  of  chromatolysis  are  what  subtend  some,  if  not  most, 
of  the  phenomena  of  Shell-shock.  On  account  of  the  myriad 
interconnections  of  neurones  and  the  remote  effects  upon 
normal  neurones  of  disturbances  of  a  microchemical  or  micro- 
physical  nature  in  a  few  neurones,  it  would  not  do  to  throw 
out  of  court  forthwith  such  a  contention  as  that  of  Mott  by 
triumphantly  pointing  to  the  miracle  cures  of  certain  Shell- 
shock  phenomena;  for  it  will  not  necessarily  be  the  chro- 
matolytic  (or  otherwise  microchemically  or  physically  altered) 
cells  that  will  be  directly  responsible  for  the  symptoms  in 
question.  Cells  whose  activity  is  but  temporarily  in  abey- 
ance (perhaps  by  phenomena  akin  to  diaschisis)  might  be 
reached  from  an  unusual  source  in  the  process  of  "  miracle 
cure,"  whereupon  the  newly  opened  paths  of  energy  might 
conceivably  remain  open.  Nevertheless,  it  cannot  be  denied 
that  there  are  considerable  stretches  of  speculation  in  the 
thread  of  this  hypothesis. 

92.  Particularly  important  is  the  question,  how  frequently 
such  hemorrhages  as  those  found  by  Mott  in  Case  197  occur. 
Cases  are  given  in  the  text  which  show  such  hemorrhages. 

Rather  often  quoted  in  this  relation  is  Case  201,  a  case  of 
Sencert,  in  which  a  shell  exploded  one  metre  away  from  a 
soldier  and  injured  him  so  that  he  died  that  night  through 
the  bursting  of  the  pleura  of  both  lungs  within  a  thoracic 


886  EPiCRisis 

cage  which  was  quite  intact.  This  sort  of  finding  reminds  one 
of  cases  in  which  the  inner  partitions  of  houses  are  burst  by 
explosion  when  the  outer  walls  remain  intact.  In  particular, 
one  thinks  of  the  physical  changes  within  an  aneroid  barom- 
eter, which  have  been  shown  to  come  about  when  something 
is  exploded  near  by.  If  such  an  event  may  happen  as  the 
bursting  of  the  lungs  within  an  otherwise  intact  body,  so 
also  is  there  evidence  that  a  similar  event  occurs  in  the  ner- 
vous system.  Clinical  evidence  of  this  is  obtained  in  the 
hemorrhage  and  pleocytosis  of  spinal  fluid  obtained  early  in 
the  clinical  examination  of  certain  cases.  In  fact.  In  Case 
205  (one  of  Souques),  there  is  a  pleocytosis  of  the  fluid  as 
late  as  a  month  after  shell-shock.  When  there  is  no  pleocyto- 
sis or  hemorrhage,  there  may  be  a  hypertension  of  the  fluid, 
—  a  finding  sometimes  attributed  to  Dejerlne  (see,  for  ex- 
ample, Case  207,  of  Leriche).  It  might  be  Inquired  whether 
the  fall  sustained  by  the  patient  as  a  result  of  the  shell  ex- 
plosion could  not  be  responsible  for  the  hemorrhage,  and  this 
may  Indeed  be  the  fact  in  certain  instances.  Bablnski  has 
offered  in  Case  209,  an  instance  in  which  hematomyella 
(with  later  partial  recovery)  was  produced  in  a  subject  who 
was  lying  prone  in  the  performance  of  machine-gun  duty  (the 
phenomena  In  this  case  were  well  described  by  the  victim  him- 
self, a  veterinary  student  who  was  six  months  a  captive  In 
Germany),  Doubtless,  it  would  not  be  difficult  to  produce 
a  complete  series  of  cases  with  and  without  trauma  to  the 
tissues  investing  the  nervous  system,  with  definite  clinical 
or  autopsy  evidence  of  organic  lesions  of  the  nervous  system, 
whether  by  mechanical  impact,  by  the  concussion  (windage) 
of  the  air,  or  even  by  the  effects  of  muscular  contractions. 

93.  A  case  of  Chavlgny's  (Case  198),  In  which  there  was  an 
extremely  careful  autopsy,  showed  a  strongly  blood-stained 
cerebrospinal  fluid;  In  fact,  there  was  an  intradural  hemor- 
rhage, though  of  minor  degree  and  possibly  not  the  cause  of 
death;  and  throughout  the  brain  substance  there  were  slight 
hemorrhagic  points.  But  there  was  no  sign  whatever  of  frac- 
ture of  the  cranial  vault  or  base.  Another  case  of  similar 
meningeal  hemorrhage  but  sharply  localized,  was  Case  199,  an 
instance  of  minor  explosion  in  which  neither  skin  nor  muscles, 


EPICRISIS  887 

bone  or  viscera  showed  any  lesion;  and  the  death,  which 
occurred  in  seven  days,  seemed  hardly  explicable  on  the  basis 
of  hemorrhage  itself.  In  fact,  this  case  would  require  the 
sort  of  microscopic  examination  performed  by  Mott  in  Case 
197  for  a  proof  of  the  cause  of  death,  which  was  thought  by 
the  reporters  themselves  (Roussy  and  Boisseau)  to  be  within 
the  field  of  histology. 

94.  Case  200  seems  to  bring  proof  that  there  may  be  areas 
of  gross  softening  within  the  spinal  cord  produced  by  the 
concussion  of  the  cord  from  shell-burst,  although  there  had 
been  no  fracture  of  the  spine  itself  and  no  penetration  of 
splinters  of  shell  or  of  bone  into  the  spinal  canal  or  the  sub- 
stance of  the  cord  itself.  The  argument  here  is  that  the 
tissues  that  lie  between  the  agent  of  violence  and  the  interior 
of  the  spinal  cord  are  affected  en  bloc  by  the  impact,  the  re- 
sultant gross  or  molar  lesions  being  several  millimetres  or 
centimetres  from  the  point  reached  by  the  impinging  body  or 
force.  How  complicated  such  a  situation  might  be,  we  may 
recall  from  a  case  previously  studied,  namely.  Case  103 
(Lhermitte) ,  wherein  a  missile  struck  the  left  side  of  the  skull 
and  produced  lesions  beneath  its  point  of  impact,  but  at  the 
same  time  apparently  caused  a  contre-coup  effect  upon  the 
opposite  hemisphere.  That  particular  case  did  not  come  to 
autopsy,  but  Lhermitte's  explanation  of  its  queer  association 
of  aphasia  with  ipsilateral  hemiplegia  seems  sound  enough. 
In  fine,  what  with  the  mechanical  trauma  to  which  many 
victims  of  shell  explosion  are  subject,  what  with  the  findings 
in  sundry  autopsies,  and  what  with  the  determination  of 
hemorrhage  in  the  spinal  fluid  early  after  the  shock,  it  might 
be  conceived  that  the  majority  of  cases  of  Shell-shock  are 
actually  cases  of  mechanical  injury  to  the  brain  or  spinal 
cord  in  which  hemorrhage  or  laceration  and  overriding  of 
neuronic  tissues  would  be  found.  Nor  would  such  a  hy- 
pothesis be  prima  facie  absurd  with  the  evidence  afforded  by 
certain  cases  ot  Shell-shock  having  an  admixture  of  reflex 
phenomena  and  other  symptoms  proved  by  the  older  neurol- 
ogists to  be  beyond  peradventure  organic.  (Compare,  for 
example,  such  a  case  as  that  of  Case  210,  with  herpes  zoster 
and  segmentary  symptoms.)     It  should  be  remembered,  how- 


EPICRISIS 

ever,  that  Mott  in  the  case  cited  above  (Case  197)  sharply 
distinguishes  between  the  hemorrhages  (especially  the  bulbar 
hemorrhage  which  caused  death)  and  the  nerve  cell  chro- 
matolysis  which  he  regarded  as  possibly  at  the  basis  of 
Shell-shock  symptoms.  It  is  decidedly  doubtful  whether 
the  hypothesis  of  microscopic  or  larger  hemorrhages,  or  of 
local  areas  of  destruction  of  neurones  will  suffice  for  the 
explanation  of  true  Shell-shock.  This  is  not  to  say  that  in 
the  diagnosis  of  true  Shell-shock  (that  is,  roughly  speaking, 
the  psychoneurosis),  we  shall  not  need  to  concede  and  con- 
sider in  every  case  the  possibility  of  traumatic  focal  brain 
disease.  This  will  always  need  to  be  faithfully  excluded  in 
all  cases  unless  the  initial  set-up  of  symptoms  is  so  suggestive 
of  immediately  curable  psychoneurosis  that  without  further 
ado  miracle-therapy  is  undertaken  and  executed.  But  in 
virtually  all  the  slower  cases,  an  exclusion  of  organic  brain 
and  cord  disease  is  undertaken.  Admixtures  of  organic  and 
focal  phenomena  are  quite  in  the  order  of  everyday  occur- 
rence. 

95.  Especially  good  instances  of  this  co-existence  of  func- 
tional and  organic  symptoms  are  found  in  ear  cases;  and 
it  may  be  suspected  that  when,  after  the  war,  all  these  data 
can  be  suitably  gathered  and  compared,  it  will  be  from  the 
field  of  otology  that  some  of  the  most  fruitful  hypotheses  will 
be  developed.  In  the  cases  of  Shell-shock  deafness,  mechani- 
cal peripheral  factors  are  admixed  with  central  factors  in 
phenomena  admitting  in  some  ways  more  exact  diagnosis 
than  in  other  fields.  We  may  await  the  correlation  of  these 
data  by  some  worker,  equally  skilled  in  otology  and  neurology, 
with  the  profoundest  interest.  Analogous  results  may  be 
hoped  from  a  correlation  of  neurological  and  ophthalmo- 
logical  conceptions. 

96.  Suffice  it  to  say  that  the  differentiation  of  organic  and 
functional  phenomena  has  long  been  possible  on  the  basis  of 
what  we  know  concerning  various  reflexes  {e.g.,  the  Babin- 
ski  reflex  and  its  congeners) ;  and  the  net  result  of  this  work 
is  that  the  majority  of  Shell-shock  cases,  —  that  is,  cases  in 
which  the  physical  factor  shell-shock  has  entered,  —  are  prob- 
ably not  cases  in  which  a  coarse  organic  disease  could  be 


EPICRISIS  889 

proved  to  exist,  or  assumed  with  any  color  of  likelihood  to 
exist.  Even  limiting  ourselves  to  cases  in  which  the  physical 
factor  shell-shock  or  some  sort  of  impact  with  or  without 
an  external  wound  occurred,  we  shall  find  cases  enough  of  a 
truly  functional  nature,  as  indicated  by  their  reflexes,  to 
render  it  quite  impossible  to  assert  that  they  are  in  the  classi- 
cal sense  "  organic  "  cases.  Putting  these  cases  with  the 
physical  shell-shock  factors  together  with  the  other  large 
series  of  cases  in  which  precisely  similar  symptoms  occur 
without  the  presence  of  the  physical  shell-shock  factor,  we 
shall  find  ourselves  convinced  that  classical  Shell-shock  phe- 
nomena are  by  and  large  what  is  called  functional.  We  shall 
arrive  at  the  hypothesis  that  they  are  cases  of  hysteria  or 
other  form  of  psychoneurosis,  entitled  to  the  diagnosis  of 
traumatic  hysteria  (or  hysterotraumatism,  in  the  sense  of 
Charcot),  or  not,  according  to  whether  the  physical  factor 
shell-shock  was  in  evidence.  What  now  underlies  the 
concept  functiona  ,  as  we  use  it  in  Charcot's  sense  of 
hysterotraumatism,  or  in  th  e  more  modern  phrase  trau- 
matic hyster  a?  Do  we  perhaps  mean  some  microchemical 
or  microphysical  change  of  a  reversible  nature,  similar  to 
that  described  by  Mott,  e.g.,  in  Case  197?  It  is  not  possi- 
ble to  answer  this  question  at  this  time. 

97.  But  if  we  give  up  the  hypothesis  of  organic  disease  of 
the  nervous  system  (that  is,  the  hypothesis  of  coarse  lesions, 
small  or  large,  conceived  to  be  the  direct  effect  of  mechanical 
impact),  can  we  incriminate  any  other  factor?  Chemical 
factors  from  the  gas  of  bursting  she'ls  may  be  thought  of; 
yet  in  abundant  cases  there  is  no  evidence  that  these  have  been 
in  play.  They  and  a  variety  of  other  special  causes  may  be 
found  working  in  a  few  instances  but  have  nothing  to  do  with 
the  moot  question. 

98.  Upon  giving  up  the  organic  hypothesis,  the  modern 
functionalist  is  very  apt  to  run  directly  into  the  embrace  of 
hysteria.  If  a  thing  is  not  physical,  it  must  be  psychical  in 
its  genesis,  so  runs  the  argument.  What,  after  all,  is  a  neu- 
rosis? We  mean  ordinarily  by  neurosis,  something  functional 
rather  than  structural.  We  often  mean  something  psychical 
rather  than  peripheral.     Accordingly,  as  we  have  seen,  many 


890 


EPICRISIS 


writers  rush  to  the  hypothesis  that  Shell-shock  effects,  except 
in  a  few  unusual  instances  of  organic  disease,  are  functional; 
and  not  only  are  they  functional  but  psychic,  and  main- 
tained by  some  of  the  so-called  "  mechanisms  "  which  abound 
in  modern  speculative  writing. 

99.  Case  253,  a  case  of  Tinel,  may  serve  to  illustrate  this 
point.  Tinel' s  patient  was  not  subject  to  shell-shock  at  all, 
but  was  wounded  in  the  arm.  Three  weeks  later,  he  was  able 
to  flex  his  forearm  only  by  means  of  the  supinator  longus. 
It  was  found  that  the  biceps  was  soft  and  flaccid,  though  the 
electrical  reactions  of  the  biceps  were  normal.  Now,  since 
flexion  of  the  forearm  is  normally  produced  by  a  synergic  con- 
traction of  the  biceps  and  supinator  longus,  the  situation  in 
Tinel's  case  was  striking  in  that  the  functions  of  the  biceps 
and  supinator  longus  had  been  separated  out  by  a  process 
which  could  not  be  hysterica  .  The  hypothesis  is  that  in 
hysteria  it  has  always  been  found  impossible  to  split  the 
synergic  action  of  these  two  muscles.  What  has  happened? 
In  Tinel's  picturesque  phrase,  the  biceps  muscle  has  been 
stupefied  by  a  process  which  involved  no  destruction  of  a 
ner\'e  trunk  or  any  important  ner\'e  elements.  This  process 
of  stupefaction  passed  away  with  a  few  weeks'  massage  and 
rhythmic  faradism.  But  what  is  this  process  of  stupefaction, 
as  Tinel  calls  it?  No  definite  answer  can  be  given.  But  is 
not  the  process  analogous  to  what  may  happen  in  a  variety  of 
cases  of  shell  explosion  in  which,  for  one  reason  or  another, 
sundry^  neurones  are,  as  it  were,  stupefied,  stunned,  anes- 
thetized, or  thrown  out  of  gear  by  some  internal  physico- 
chemical  readjustment  of  unknown  nature?  Perhaps  that 
readjustment,  though  in  Tinel's  case  it  probably  took  place 
within  the  tissues  of  the  arm  itself,  is  analogous  to  the  chro- 
matolytic  process  in  ner\'e-cell  bodies  suspected  by  ]\Iott  to 
be  at  the  bottom  of  certain  Shell-shock  symptoms  as  in  Case 
197. 

100.  Are  there,  then,  phenomena  of  peripheral  nerve  shock 
analogous  to  the  phenomena  of  spinal  cord  and  brain  shock 
which  we  find  in  so  many  cases?  But  if  so,  it  is  clearly 
unnecessary,  and  indeed  injurious  for  us  to  conceive  that 
cases  proved  not  to  be  organic  must  necessarily  be  hysterical. 


EPICRISIS  891 

Several  authors  have  called  a  halt  upon  this  undue  extension 
of  the  concept  of  hysteria  to  include  all  the  non-organic 
phenomena.  Take,  for  example,  the  case  of  the  Victoria 
Cross  winner  (Case  529),  reported  by  Eder,  in  which  a  con- 
tracture was  shown  by  hypnosis  to  be  a  representation  of  the 
patient's  clutch  upon  his  bayonet  (he  had  been  at  Gallipoli 
and  was  wounded  in  fourteen  places  during  a  bayonet  fight 
with  Turks).  It  would  not  be  possible  —  in  fact,  It  would 
seem  almost  impolite  —  to  refuse  to  entertain  the  hypothesis 
of  a  kind  of  symbolism  in  the  bayonet-clutch  contracture  of 
Eder's  case;  but  it  would,  on  the  contrary,  be  far  from 
exact  to  consider  all  cases  of  contracture  to  be  even  probably 
or  possibly  symbolic  in  the  manner  of  the  bayonet-clutch. 
There  are,  many  workers  feel,  many  functional  phenomena 
that  are  non-hysterical,  and  as  it  were  infra-hysterical  in  the 
sense  that  the  "  mechanisms"  (to  use  that  over- worked  term) 
are  in  neurones  below  the  level  of  complexity  required  by 
hysteria.  This  theoretical  possibility  (that  the  functional 
should  be  divided  into  the  psychical  and  the  infrapsychical) 
has  been  given  a  new  status  by  the  work  of  Babinski  and  his 
associates.  That  work  seems  to  show  that  the  older  doctrines 
of  Charcot  concerning  the  existence  of  "  reflex  "  disorders, 
are  perfectly  sound. 

loi.  Babinski  has  been  able  to  bring  into  the  light  of 
observation  the  morbid  operation  of  certain  of  these  reflex 
arcs.  Even  in  cases  where  in  the  waking  life  the  central 
nervous  system  is  able  to  overpower  the  reflex  arcs  in  question 
and  permit  the  limb  or  limbs  to  work  reasonably  well  and 
smoothly,  the  process  of  chloroform  anesthesia  will  quickly 
bring  out  an  odd  and  unsuspected  interior  situation.  The 
chloroform  suspends  the  operation  of  numerous  neurones, 
including  those  that  have  to  do  with  the  downfiow  of  cerebral 
inhibitions,  those  si  ent  streams  of  impulse  that  serve  to 
keep  the  knee-jerks,  for  example,  in  leash.  Now  at  a  time 
when  all  the  other  muscles  of  the  body  are  relaxed,  the  with- 
drawal of  the  cerebral  inhibitions  by  chloroform  anesthesia 
may  cause  a  phenomenon  to  appear  in  certain  reflex  arcs  that 
argues  an  excess  of  activity;  thus  in  the  leg,  for  example,  an 
ankle-clonus,  or  a  patella-clonus,  or  a  degree  of  contracture, 


892  EPICRISIS 

may  be  brought  about  early  in  chloroform  anesthesia,  though 
there  had  been  little  or  no  suspicion  of  such  a  tendency  in  the 
waking  life.  The  cerebral  inhibitions  in  the  waking  life 
have  been  enough  to  dampen  the  ardor  of  the  reflex  arc  in 
question.  It  must  be  remarked  that  these  cases  of  reflex,  or, 
as  Babinski  termed  them,  physiopathic  disorders,  as  a  rule 
occur  in  cases  locally  wounded.  It  is  the  locally  wounded 
limb  that  develops  functional  excess  of  contained  reflex  arcs. 
Does  this  occur  by  a  process  of  neuritis,  or  by  some  other 
unknown  process?  Whatever  the  answer  to  this  question, 
Babinski  and  his  associates  appear  to  have  shown  the  exist- 
ence of  a  group  of  physiopathic  or  reflex  disorders ;  disorders 
below  the  level  of  the  psyche  and  below  the  theatre  of  oper- 
ations of  hysteria. 

102.  Practically  speaking,  also,  it  is  important  not  to 
consider  every  functional  situation  hysterical,  since  the  non- 
hysterical  functional  changes  may  be  extremely  obstinate  to 
treatment.  Both  physician  and  patient  suffer  If  the  patient 
is  treated  along  psychotherapeutic  lines  for  hysterical  symp- 
toms, some  of  which  turn  out  on  Investigation  to  be  functional 
enough  but  non-psychic.  The  peculiar  configuration  of 
symptoms  shown  In  cases  with  the  physical  shell-shock  or  Its 
equivalent,  is  perhaps  dependent  upon  what  neurones  are 
locally  affected.  If  there  has  been  good  evidence  of  near-by 
explosion  or  of  wound,  it  will  be  especially  important  to 
learn  just  what  parts  of  the  nervous  system  and  just  what 
synergic  neurones  and  other  structures  were  affected. 
Whether  the  process  within  these  neurones  be  one  analogous 
to  the  dissolution  of  chromatin,  or  whether  the  process  is 
more  like  one  of  narcosis,  or  narcosis  and  stupefaction,  or 
whether  the  process  Is  more  like  that  of  a  stun,  or  like  the 
plight  of  the  nerves  in  a  foot  for  a  long  time  "  asleep,"  it  may 
be  impossible  to  say;  but  It  is  entirely  unnecessary  to  soar 
directly  to  the  higher  mental  process,  unnecessary  In  short, 
to  assume  a  hysterical  dissociation  when  the  dissociation  may 
be  far  lower  down  in  the  nervous  system. 


epicrisis  893 

The  Treatment  of  Shell-shock  Neuroses 

103.  We  have  pictured  the  practical  situation  in  which  the 
neuroses  of  the  war  find  themselves  —  a  situation  bristHng 
with  diagnostic  difficulties.  The  great  proposition  deducible 
therefrom  is, 

The  diagnostic  problem  in  Shell-shock  is  the  diagnostic 
problem  of  neuropsychiatry  at  large 

The  neuroses  of  war  have  this  in  common  with  the  neuroses 
of  peace  —  that  they  need  to  be  distinguished  from  all  other 
nervous  and  mental  diseases.  One  cannot  be  a  specialist  in 
Shell-shock  unless  one  is  a  neuropsychiatric  specialist;  even 
the  neuropsychiatrist  has  much  to  learn  from  the  internist, 
the  orthopedist,  the  neurosurgeon,  as  well  as  from  the  psychol- 
ogist. 

But  however  wide  the  diagnostic  field  for  Shell-shock,  the 
therapeutic  field  is  wider  still.  For  the  neuropsychiatric  re- 
constructionist  has  to  face  the  peculiarities  of  the  military 
status  of  his  ward,  the  difficulties  of  demobilization  into 
civilian  Ijfe  (a  canal  system  with  very  precise  technic  for  the 
opening  and  closing  of  locks),  the  choice  and  timing  of  the 
proper  measures  of  bedside  occupation,  of  occupation  therapy 
in  a  broader  sense,  of  prevocational  and  vocational  training 
—  the  whole  comp  icated  by  the  character  changes  that  may 
have  set  in  to  bowl  over  all  one's  preconceptions.  The  nub 
of  the  matter,  after  the  era  of  the  maniere  forte,  the  brusque 
psychotherapy,  the  rough  jarring  of  the  man  back  into  ap- 
proximate normality  is,  perhaps,  this  potentiality  of  subtle 
character  changes  defying  possibly  anybody's  analysis,  but 
stimulating  us  all  to  our  best  endeavor,  whether  we  are  physi- 
cians, psychologists,  occupation-workers,  social  workers,  or 
nurses.  Now  that  all  sorts  of  reconstruction  programs  are 
in  the  air,  each  claiming  its  share,  or  more  than  its  share,  of 
attention,  let  us  not  forget  that  no  one  can  stake  out  in  any 
small  plot  the  measures  of  refitting,  readjustment,  readapt- 
ation,  rehabilitation  —  all  these  terms  with  slightly  differing 
denotation  have  been  used  —  especially  when  we  take  into 
account  that  not  only  must  the  patient  be  refitted  to  his  en- 


894  EPiCRisis 

tourage,  but  also  not  seldom  the  entourage  to  its  returned 
Shell-shocker. 

104.  It  is  proper  to  place  these  general  considerations  first 
because  the  slow,  patient,  prosaic  measures  of  reeducation 
are  apt  to  be  forgotten  in  our  enthusiasm  for  the  lightning- 
like cures  of  the  hypnotic,  the  psychoelectric,  the  pseudo- 
operative,  and  other  psychotherapeutic  forms.  Psychother- 
apy in  all  its  forms  has  come  into  its  own  in  Shell-shock. 
Miracles  or  their  equivalents  are  daily  wrought  by  men  who 
are  not  prophets.  Lourdes  and  Christian  Science  have  their 
unassuming  rivals.  Let  us  remember,  however,  that  even 
Lourdes  and  Christian  Science  never  solved  100%  of  the 
problems  placed  before  them,  even  though  the  votaries  have 
the  best  will  in  the  world  to  be  cured.  If  the  will  itself  is 
disordered,  what  can  be  done  save  investigate?  And  the 
mauvaise  volonte  is  by  no  means  absent  from  some  of  our 
prospective  patients;  witness  one  man,  a  Frenchman,  who 
so  resented  being  cured  by  tor  pillage,  i.e.,  by  the  electric 
brush,  that  he  carried  his  case  against  Clovis  Vincent,  who 
cured  him  of  his  hysteria,  clear  to  the  Academy!  And,  even 
after  we  have  cured  our  cases  by  these  modern  miracles,  let 
us  not  be  too  proud  of  ourselves!  One  soldier  sent  back  to 
Australia,  hysterically  mute  for  months,  got  his  voice  back 
after  killing  a  snake  —  a  peculiar  instance  of  occupation- 
therapy,  not  enumerated  in  courses  on  reconstruction.  And 
remember  the  man  who  jumped  the  wall  and  got  drunk, 
breaking  back  into  the  hospital  to  show  his  doctor  how  his 
refractory  voice  had  at  last  come  back.  Thus  there  are  cures 
and  cures  (even  a  newspaper  cure  of  mutism  by  a  moving 
picture  vision  of  the  antics  of  Charlie  Chaplin),  and  spon- 
taneous non-medical  cures  as  well  as  medical  ones,  and  slow 
cures  due  to  vis  medicatrix,  as  well  as  to  shrewd  reeducation 
measures. 

105.  I  shall  not  attempt  to  cover  systematically  the  topic 
of  Shell-shock  therapy  In  this  epicrlsls.  The  reader  must  go 
through  the  treated  cases,  especially  In  Section  D  but  passim 
elsewhere.  If  he  is  to  obtain  a  proper  conception  of  all  the 
methods  so  far  employed  —  and  at  the  end  he  cannot  know 
the  ultimate  outcome  of  the  cases.     Patrons  of  the  miracle 


EPICRISIS  895 

cures  and  the  maniere  forte  are  having  their  day :  on  the  whole, 
the  law  of  sudden  onset,  sudden  ending  has  much  to  say  for 
itself  in  the  hysterical  (pithiatic)  group.  Forebodings  of 
relapse  in  these  torpedoed  cases  may  indeed  have  some  foun- 
dation :  but  figures  are  yet  lacking,  and  relapses  may  be  as 
expectantly  predicted  in  the  slow-onset,  slow-cure  group. 
The  decision  must  be  post-bellum.  Nor  must  the  fact  that 
a  few  absolutely  normal  subjects  have  succumbed  de  novo 
to  Shell-shock  blind  us  to  the  fact  that,  statistically  speaking, 
most  cases  are  ab  ovo  psychopaths  in  whom  relapses,  recur- 
rences, or  new  instances  of  neurosis  may  be  confidently  ex- 
pected. For  these  ah  ovo  psychopaths,  what  can  suffice  but 
(a)  removal  of  the  disease  by  the  vis  medicatrix  naturae;  or 
{b)  reeducation,  intellectual  or  (c)  moral  (as  the  case  may  be) ; 
or  else  (d)  some  plan  of  environmental  shielding  from  new 
occasions  of  disease? 

106.  I  shall  content  myself  with  a  brief  survey  (insisting 
that  the  details  be  read  of  at  least  the  leading  cases  in 
each  treatment  subgroup)  of  the  cases  offered  in  Section  D 
(Shell-shock:  Treatment  and  Results),  consisting  of  117  cases 
(Cases  473-589).  The  cases  are  in  general  arranged  with 
the  spontaneous  and  quasi-natural  cures  at  the  outset,  — 
a  series  of  11  cases  (Cases  473-483).  The  remainder  of  the 
section  deals  with  cures  under  medical  conditions,  although 
many  cases  naturally  show  an  interplay  of  non-medical  factors 
in  the  cure  or  persistence  of  one  or  more  symptoms. 

A  few  cases  illustrative  of  the  physical  value  of  hydro- 
therapy, mechanical  therapy,  and  drugs  are  given  in  a  short 
series  (Cases  484-489).  A  treatment  of  hysterical  contrac- 
tures by  induced  fatigue  is  dealt  with  in  Cases  489-493 ;  and 
the  occasional  value  of  surgery  is  shown  by  Case  494. 

The  simpler  methods  of  persuasion  and  explanation  follow 
in  a  series  of  19  cases  (Cases  495-513). 

Pseudo-operations  and  suggestive  operative  manipulation 
of  avail  in  the  treatment  of  certain  local  hysterical  phenomena 
are  considered  in  a  series  of  eight  cases  (Cases  514-521).  The 
comparatively  long  hypnotic  series  follows:  27  cases  (Cases 
522-548).  The  above-mentioned  cures  by  pseudo-operation 
and  by  hypnosis  may  be  classified  with  those  that  follow,  i.e.^ 


896  EPICRISIS 

mainly  rapid  cures  by  psycho  electric  methods  and  by  sug- 
gestion on  emergence  from  anesthesia  (Cases  549-574.),  as 
modern  miracles  These  cases  of  modern  miracle  are  followed 
by  a  briefer  set  of  reeducative  cases  (Cases  575-589)- 

Throughout  the  treatment  section  are  scattered  instances 
in  which,  not  a  cure,  but  merely  a  modification  or  even  a 
persistence  of  symptoms  w^as  the  outcome.  It  is  useful  to 
bear  in  mind,  while  reading  cases  in  the  etiological  and  diag- 
nostic sections,  these  main  divisions  of  treatment  into  what 
might  be  called  (i)  spontaneous,  (2)  rapid  (or  "  miraculous  ") 
and  (3)  slow  or  reeducative. 

107.  It  is  beyond  the  scope  of  this  book  to  deal  systemati- 
cally with  the  hospital  and  administrative  side  of  these  ques- 
tions. Especially  the  zone  question  is  of  practical  importance, 
that  is,  the  question  of  arrangements  at  the  front,  on  evacu- 
ation lines,  and  in  the  interior.  Roussy  and  Lhermitte  have 
particularly  discussed  these  matters. 

After  thirty  months'  experience  in  the  psychiatric  centers 
of  two  armies,  Damaye  suggested  an  organization  of  psychi- 
atric centers  in  two  parts,  —  First,  a  service  draining 
patients  from  the  firing  line,  rapidly  give  them  first  care  and 
evacuate  them,  in  charge  of  special  attendants,  to:  Second,  a 
psychiatric  or  neurological  center  in  the  communication  zone 
(Stapes)  without  danger  of  bombardment  and  at  a  distance 
from  the  guns.  The  more  serious  cases  will  then  be  evacuated, 
thirdly,  into  the  interior  from  these  centers  along  communi- 
cation lines.     But  most  will  have  gotten  well  at  the  front. 

108.  By  orthopedists  and  mechanotherapeutists  too  much 
stress  may  indeed  be  laid  on  non-psychiatric  measures,  as 
Duprat  hints.  Yet  perhaps  neuropsychiatrists  may  need 
as  much  coaching  in  the  opposite  direction.  One  must 
remember  the  non-psychopathic  fraction  of  these  Shell-shock 
disorders  and  their  need  of  diathermy  (Babinski).  Duprat 
says  that  the  centers  for  physiotherapy  cannot  effectively  do 
the  work  of  all  Shell-shock  therapy,  as  the  physiotherapists 
have  their  aims  fixed  on  nerves  and  muscles  rather  than  the 
mind.  Each  case  requiring  psychotherapy  ought  to  be 
studied  in  an  experimental  psychological  laboratory  from  a 
number  of  points  of  A^ew  such  as  mechano-motor  capacity. 


EPICRISIS  897 


PSYCHOELECTRIC  AND  REEDUCATIVE  TREATMENT 

Phase      I.   PERSUASIVE  TALK   IN   CONSULTING   ROOM 
Phase    II.    ISOLATION,  REST  IN  BED,  MILK  DIET  (a  few  days) 

Phase  III.   FAR.\DIZATION 

Phase   IV.    REEDUCATION    (Physiotherapy  and  Psychotherapy) 

Phase     V.   AFTER-CARE 

Curing  a  psychoneuropath  means  victory  in  a  moral  battle! 

After  Roussy  and  Lhermitte 


Chart  19 


898  EPICRISIS 


TREATMENT  FOR  INVETERATE   HYSTERICS 

Phase      I.   "  TORPILLAGE "     AND     INTENSIVE     REEDUCA- 
TION 

Phase     II.   FIXATION   OF    PROGRESS   BY   EXERCISES 

Phase  III.   PROLONGED   SPECIAL  TRAINING 

After  Clovis  Vincent 


Chart  20 


EPICRISIS  899 

the  sensibility,  emotional  and  intellectual  sides,  memory, 
impulses  and  the  like.  Testing  apparatus  should  be  available 
together  with  dynamometers,  sphygmometers,  chronoscopes, 
ergographs,  pneumographs,  cardiographs  and  recording  ap- 
paratus. 

Specialists  for  consultation  should  be  available,  including 
ophthalmologists,  otologists,  laryngologists  and  electrical 
specialists.  The  tests  over,  the  patient  should  be  examined 
as  it  were,  in  a  free  state  and  his  habits  and  character  noted. 
Hypnosis  may  be  tried  but  it  should  not  be  prolonged. 
Psychic  contagion  is  to  be  avoided  especially  in  the  case  of 
subjects  with  epileptoid  crises. 

It  would  be  well  to  establish  for  the  cases  regarded  as  sus- 
ceptible to  psychotherapy,  reeducation  centers  like  those  for 
the  re-adaptation  of  the  tuberculous.  The  improved  tuber- 
culous are  sent  to  health  centers  under  the  Ministry  of  the 
Interior  for  three  months  at  the  maximum  and  emerge  much 
better  able  to  support  the  exigencies  of  life.  According  to 
Duprat,  there  ought  to  be  psychotherapy  centers  which  should 
not  in  any  sense  recall  asylums  for  the  insane.  Set  in  the 
country  but  not  far  from  the  city,  managed  by  the  psycho- 
logical physicians  and  "  medecins  psychologues,  plus  educateurs 
que  medecins.''^  The  personnel  should  consist  of  students 
going  into  psychiatry  and  of  teachers  whose  pedagogical 
practice  ought  to  enable  them  to  second  the  efforts  of  the 
psychiatrists.  In  this  way  we  might  avoid  the  perpetuation 
of  some  of  the  psychopathies  of  war. 

109.  Possibly  "  putting  forward  the  best  foot "  may 
yield  a  wrong  impression  of  the  proportion  of  what  I  have 
termed  "  miracle  cures."  Other  devices  of  a  slower  nature 
are  mentioned  throughout  the  book.  Perhaps  much  de- 
pends on  the  temperament  of  the  psychotherapeutist,  as  e.g., 
Laignel-Lavastine  has  remarked  about  the  method  of  psycho- 
therapy by  means  of  conversation :  that  one  might  easily  re- 
main in  a  honeymoon  state  in  military  psychotherapy.  When 
hundreds  and  thousands  of  functional  nervous  cases  pass 
through  one's  hands  it  is  necessary  to  remember  that  behind 
the  conversation  there  stands  the  imposing  finger  of  material 
force. 


900  EPICRISIS 

Compare  the  work  of  Clovis  Vincent,  Yealland,  Kaufmann. 
no.  On  the  other  hand,  Rows  points  out  that  shock  is  a 
term  that  does  not  explain  at  all  adequately  the  great  variety 
of  mental  illnesses  occurring  in  the  soldiers  at  the  front.  The 
term  is  popularly  used  for  cases  which  recover  quickly,  but 
in  the  majority  of  cases  there  is  a  residuum  after  the  shock  has 
disappeared.  Accordingly  Rows'  work  has  dealt  chiefly  with 
underlying  causes,  conditions,  and  factors.  Here  we  may 
consider 

(a)  The  war  strain  before  breakdown ; 
{b)  Special  causes  of  shock,  such  as  death  of  comrades 
near  by,  near-by  shell  explosions  and  blowing  up 
of  trenches; 

(c)  Fatigue   and   exhaustion  with  lowered  capacity  of 

resistance. 
The  men  themselves  find  that  they  have 

(d)  undergone  a  change  of   character,   having   become 

irascible,  unable  to  sustain  interest  and  attention; 
solitary  and  morose,  and  less  capable  of  self-con- 
trol. Anxiety,  worry  and  a  state  of  morbid  ex- 
pectancy set  in.  Everyday  trifles  are  exaggerated. 
But  below  these  cases  are  still  deeper  ones,  such 
as 

(e)  revival  of  horrible  memories  and  terrifying  dreams 

of  war  scenes,  together  with  memories  of  incidents 

of  past  life. 

(Rows  attributes  to  Dejerine  the  idea  that  the 

cause  of  all  cases   of  hysteria   and  neurasthenia 

must  be  sought  in  antecedent  emotion.) 
Emotion  compels  attention,  and  to  such  a  degree  in  some 
cases  that  the  memories  and  attendant  fears  and  anxieties 
cannot  be  expelled.  Hallucinations  and  delusions  may  then 
develop.  The  patient  is  largely  incapable  of  reasoning  about 
his  status;  he  lacks  "  insight  into  the  nature  and  mode  of 
origin  of  his  mental  illness.  This  insight  can  be  provided  by 
explaining  to  him  in  plain  language  the  mechanism  of  simple 
mental  processes,  by  enabling  him  to  understand  that  every 
incident  is  accompanied  by  its  own  special  emotional  state, 
and  that  this  emotional  state  can  be  re-awakened  by  the  re- 


EPICRISIS 


901 


vival  of  the  incident  in  memory."  The  patient  and  the 
physican  now  "  begin  to  realize  that  they  have  some  ground 
in  common.  .  .  .  The  mystery  of  the  illness  will  be  swept 
away  and  the  physician  will  be  able  to  .  .  .  show  him  how 
he  can  educate  himself  to  regain  that  which  was  lost." 
"  The  patient  can  be  induced  to  face  the  trouble."  "  The 
excessive  emotional  tone  will  thus  be  stripped  away  and  the 
patient  will  thus  become  able  to  appreciate  the  real  value  of 
the  Incident."  "  The  reeducation  must  vary  with  each 
case  In  order  to  overcome  the  difficulties  connected  with  the 
specific  cause  which  has  been  discovered." 

Rows'  work  has  been  done  at  the  Red  Cross  Hospital  at 
Maghull,  and  several  of  the  MaghuU  cases  have  been  reported 
in  Elliot  Smith  and  T.  H.  Pear's  book  on  Shell-shock.  A 
somewhat  similar  point  of  view  has  been  maintained  by 
Wm.  Brown,  who  has  suggested  the  neat  term  autognosis  for 
psychoanalysis.  W.  A.  Turner  speaks  of  the  Maghull  point 
of  view  as  one  of  modified  psychoanalysis. 

111.  Or  again  a  species  of  combination  of  the  manihre  forte 
and  the  maniere  douce  (operations,  shall  we  say  with  William 
James,  of  the  "  tough-minded  "  and  the  "  tenderminded  " 
respectively?)  may  be  used  as  in  the  formula 

SYMPATHY  +  FIRMNESS   (Mott). 

112.  More  special  devices,  suggesting  faintly  the  methods 
of  animal  training,  may  be  used,  as  described  in  the  following 
account  of  a  new  isolation  and  psychotherapeutic  service 
established  In  May,  1915,  at  the  Salpetri^re  for  soldiers  with 
functional  nervous  diseases.  The  basic  idea  has  long  been 
held  by  Dejerine,  —  the  avoidance  of  heterosuggestion  by 
other  patients,  imitation,  11  effects  of  visits  from  members  of 
the  family.  The  functional  additions  that  come  from  near-by 
organic  patients  are  among  the  disadvantages  of  the  ordinary 
treatment.  The  isolation  service  of  the  neurological  center  Is 
composed  of  34  beds,  arranged  In  two  halls,  with  three  extra 
rooms.  Each  bed  is  isolated.  The  regime  in  one  of  the  rooms 
is  more  rigorous  than  in  the  other,  and  it  is  an  advance  for  a 
patient  to  be  moved  from  the  first  to  the  second  room.  The 
patient  on  wakening  has  no  right  to  leave  his  box  or  com- 


902  EPICRISIS 

municate  with  his  neighbors.  He  leaves  only  to  be  treated 
by  hydrotherapy  or  electrotherapy.  He  takes  his  meals  in 
isolation,  receives  no  calls,  and  has  no  leave  to  go  out.  The 
physician  sees  the  patient  twice  a  day  and  carries  on  psycho- 
therapy and  motor  reeducation,  as  well  as  special  treatments. 

Women  nurses  care  for  the  patients.  A  system  of  control 
and  of  progressive  rewards  has  been  installed,  being  a  sort  of 
metric  evaluation  of  the  process  of  cure.  As  the  cure  pro- 
ceeds the  patient's  lot  is  progressively  mitigated,  or  if  he  gets 
worse  the  regime  is  clamped  down.  Suppose  a  man  a  vic- 
tim of  paralysis  of  leg  —  the  height  to  which  he  can  lift  his 
leg  is  measured  in  centimeters  daily  as  well  as  the  time  during 
which  he  can  hold  the  eg  in  air;  or,  the  progress  of  an  ankle, 
or  of  the  forearm  or  the  arm  in  a  case  of  arm  contracture, 
is  measured.  The  grade  obtained  by  our  scholar  in  psycho- 
therapy is  inscribed  upon  a  slate.  Finally,  walks,  concerts, 
visits  and  eventually  permission  to  go  out  into  the  town  are 
granted. 

113.  Can  Shell-shock  neuroses  be  prevented,  other  than 
by  stopping  or  modifying  the  war  or  by  weeding  out  Shell- 
shock  candidates  as  they  volunteer  or  are  drafted?  Morton 
Prince  offers  points  of  some  suggestive  value.  The  very 
various  proportions  of  neurosis  observed  in  different  units 
and  arms  of  the  service  suggest  that  various  degrees  of  pre- 
paredness may  have  played  a  part.  Bemheim  says  sug- 
gestion is  an  idea  accepted.  Aside  from  a  possible  increase 
of  simulation,  much  might  depend  on  what  idea  administered 
really  got  accepted!  Morton  Prince's  plan  is  that  the  pre- 
vention must  be  based  upon  the  education  of  the  mind.  This 
therapeutic  education  should  be  based,  however,  on  a  pre- 
liminary systematic  study  by  a  board  of  specialists  in  the 
psychoneu roses  of  (a)  the  mental  attitude  of  minds  generally 
toward  shell  fire,  and  (b)  clinical  varieties  of  this  "  shock  " 
neurosis  as  it  occurs  in  trench  warfare,  (c)  its  frequency  and 
disabling  incidence,  and  (d)  the  state  of  mind  previous  to  the 
trauma  of  those  suffering  from  it. 

On  the  basis  of  the  findings  of  such  a  study,  first,  the  regi- 
mental surgeon  through  lectures  and  clinical  demonstrations 
would  be  instructed   systematically  in  the   symptoms   and 


EPICRISIS  903 

pathology  of  the  disease  and  the  methods  of  psychotherapy 
for  its  prevention. 

Second,  soldiers,  including  officers,  could  then,  in  units  of 
say  100,  in  turn  be  instructed  in  the  nature  of  the  disease 
through  lectures  by  regimental  surgeons.  Shell-shock,  they 
should  be  told,  is  a  form  of  hysteria  caused  by  mental  factors. 
The  work  of  the  instruction  should  be  done  in  France  in  the 
atmosphere  of  the  war,  wherein  would  be  formed  an  attitude 
of  healthy  mental  preparedness  instead  of  an  attitude  of  fear 
and  mystery.  Has  mental  hygiene  this  great  scope?  Is 
morale  merely  education? 

114.  What  after  all,  is  Morale?  We  hope  to  learn  a  little 
about  it  from  this  war  for  use  hereafter,  when  we  can  say 
with  the  Florentine 

e  quindi  uscimmo  a  riveder  le  stelle 

And  thence  we  issued  out  again  to  see  the  stars 

Inferno,  Canto  xxxiv,  139. 


BIBLIOGRAPHY  OO5 


BIBLIOGRAPHY 

These  references  were  collected  in  the  main  by  Sergeant  Norman  Fenton 
both  before  and  after  his  entering  the  army,  in  connection  with  preparations 
for  the  work  of  one  of  the  Neuropsychiatric  Training  Schools  (that  at  Boston), 
established  by  the  Division  of  Neurology  and  Psychiatry  of  the  Surgeon-Gen- 
eral's Office,  U.  S.  Army.  The  work,  through  the  year  191 7,  at  least,  is  not  a 
mere  vernis  de  bibliographe,  but  is  based  on  a  first-hand  search  through  journals 
available  in  the  Boston  Medical  Library  and  the  New  York  Academy  of  Medi- 
cine (to  whose  officers  thanks  are  due  for  very  special  privileges  accorded). 
After  Sergeant  Fenton's  departure  for  service  in  the  war  neurosis  hospital,  117, 
American  E.  F.,  France,  the  work  was  finished  by  the  writer  in  considerable 
haste  by  skimming  the  current  indexes  and  gathering  the  mcT-e  prominent  titles 
for  1918  (some  for  1919).  The  titles,  be  it  noted,  go  beyond  the  scope  of  the 
case-material  in  the  body  of  the  book  and  cover  also  a  variety  of  reconstructional, 
reeducational,  clinical-neurological,  neurosurgical,  and  other  topics  bearing  in- 
directly on  neuropsychiatry.  These  auxiliary  subjects  are  by  no  means  com- 
pletely covered,  but  it  was  thought  the  titles  might  help  other  inquirers.  Under 
the  war  conditions  numerous  errors  have  no  doubt  crept  into  the  references, 
which  errors  we  hope  will  not,  by  reason  of  the  short  space  of  time  covered  by 
the  bibliography,  prove  particularly  misleading.  The  auxiliary  topics  can  be 
referred  to  in  the  Index  under  page-numbers  after  the  word  "Bib." 

E.  E.  S. 

Abadie.     La  neuro-psychiatrie  d'urgence  aux  armees.     Presse  Med.,  Par.,  1915, 

V.  23,  p.  46. 
Abrahams,  Adolphe.     A  case  of  hysterical  paraplegia.     Lancet,  Lond.,   191 5, 

V.  ii,  p.  178. 
Abrahams,A.     "  Soldier's  Heart."     Lancet,  Lend.,  I9i7i  i.  442- 
Absence  of  neuroses  in  war.     N.  York  M.  J.,  1916,  v.  103,  p.  1178- 
Ackerley,  R.     Treatment  by  physical  methods  of  mental  disabilities  induced  by 

the  war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-1918,  v.  10  (sect.  Balneol.), 

pp.  37-38. 
Aconi,  A.     Le  nevrosi  di  cuore  e  la  guerra.     Riforma  med.,  Napoli,  1916,  v.  32, 

pp.    501-505-  ....  T.    .        ,;r     J     T 

Addinsell,  A.  W.     Head  mjunes  m  war.     Brit.  Med.  Jour.,  1916,  u,  99. 

Adler,  H.  M.     The  broader  psychiatry  and  the  war.     Mental  Hyg.,  Concord, 

N.  H.,  1917,  V.  I,  pp.  364-370. 
Adrian,  E.  D.  and  Yealland,  L.  R.     The  treatment  of  some  common  war  neuroses. 

Lancet,  Lond.,  191 7,  i,  667. 
Adrian  and  Yealland.     The  treatment  of  some  common  war  neuroses.     Lancet, 

Lend.,  1917,  i,  pp.  867-872. 
After  care  of  nerve  injuries.     Rev.  of  War  Surg.  &  Med.,  1918,  i,  no.  3,  49. 
Agostini,  C.     Sulla  utilizazione  degli  epilettici  in  zona  di  guerra.     Gior.  di  med. 

mil.,  Roma,  1918,  Ixvi,  24-33. 
Agnus,  A.     Le  cloquement  de  la  balle  et  de  I'obus.     Rev.  Scient.,  Pans,  1915,  le, 

pp.  358-363. 
Agudo   Avilla,   A.      La   guerra   y   las   enfermedades   mentales.      Prensa   med. 

argentina,  Buenos  Aires,  1916-1917,  v.  3,  pp.  129-131. 
Aime,  Henri.     De  la  variete  et  de  revolution  des  troubles    nerveux   et    psy- 

chiques  d'origine  commotionnelle  pendant  la  guerre.     Presse  Med.,  Par., 

1917,  v.  25,  pp.  113-114.  . 

Aime,  H.  et  Perrin,  E.     Considerations  sur  un  cas  d'epilepsie  partielle  guene 

apres   extraction  du  projectile  intra-cerebral.     Progres    Med.,    Par.   1916, 

v.  3,  pp.  187-189. 


9o6 


BIBLIOGRAPHY 


Aitkin,  D.  M.     Orthopaedic  methods  in  military  surgery.     Lancet,  Lend.,  191 7, 

V.  I,  pp.  10-16. 
Albert-Weil,  E.     Physiotherapie  et  blesses  de  guerre.     Paris  Med.,  1914-1915, 

(Part.  Med.),  v.  15,  p.  405. 
Alberti,  A.    I  servizi  psichiatrici  di  guerra.     Riv.  ospedal.,   Roma,   1917,  v.  7, 

pp.  2t'^~"245. 

Alienee  arrose  des  passants  avec  de  I'esprit  de  sel.  Ann.  med.-psychol..  Par., 
1914-1915,  V.  6,  p.  524. 

Allbutt,  T.  C.  Investigation  of  the  significance  of  disorders  and  diseases  of  the 
heart  in  soldiers.     Brit.  Med.  Jour.,  191 7,  ii,  139. 

Alquier,  L.  Sur  les  troubles  nerveux  par  engorgements  lymphatiques.  Rev. 
neurol.,  Par.,  191 7,  v.  24,  pp.  8-13. 

Alquier,  Paul  and  -Tanton,  J.  L'appareillage  dans  les  fractures  de  guerre. 
Collection  Horizon,  Masson  et  Cie,  Paris,  1916;  also  trans.  Engl,  in  Military 
Medical  Manuals,  Univ.  Lond.  Press,  and  in  Medical  and  Surgical  Therapy, 
D.  Appleton,  N.  Y. 

Alt,  Konrad.  Psychische  Storungen  im  Kriege.  (D.  Oester.  Sanat.,  Wien.,  1915, 
v.  12,  p.  2).  Aerztl.  Central  Ztschr.,  Wien,  1915,  also  v.  10,  pp.  1-2;  and 
1915,  V.  9,  p.  2. 

Alt,  Konrad.  Im  Deutschen  Heere  wiihrend  des  Krieges  aufgetretende  psy- 
chische Storungen  und  ihre  Behandlung.     Ztschr.  f.  arztl.  Fortbild.,  Jena 

1915,  No.  II,  pp.  331-333- 

Alt,  Konrad,     Ueber  die  Kur-  u.   Badefiirsorge  f.  ner\-enkranken   Krieger,  mit 

besonderer   Beriicksichtigung  der  sogen.     Kriegsneurotiker.      Wien.     Klin. 

Wchnschr.  Nr.  18,  1918. 
Alter,    W.     Zur    Erkenntnis    abwegger    und    krankhafter   Geisteszustande    bei 

Schulrekruten.     Psychiat. -neurol.  Wchnschr.,  Halle  a.  S.,  1914-1915,  v.  16, 

PP-  327-330;  339-341;  351-356. 
Amar,  Jules.     Le  moteur  humain.     Dunod  et  Pienat,  Pans,  1914. 
Amar,  J.     Principes  de  reeducation  professionnelle.     Compt.  rend.  acad.  d.  sc. 

Par.,  1915,  v.  160,  pp.  559-562. 
Amar,  J.     La  reeducation  des  blesses  et  mutiles  de  la  guerre.     Rev.  scient.,  1915, 

V.  53,  PP-  363-367-  ,  ,  .,,     ,    , 

Amar,  J.     La  reeducation  professionnelle  des  blesses  et  des  mutiles  de  la  guerre. 

J.  de  physiol.  et  de  path,  gen.,  1915,  p.  820;   p.  837;^  p.  855. 
Amar,  J.     Technique  d'education  sensitive  pour  amputes  et  aveugles.     Compt. 

rend.  Acad.  d.  sc.  Par.,  1916,  v.  163,  pp.  335-338- 
Amar,  J.     Organization  of  vocational  training  for  war  cripples.     Am.  J.  Care 

Cripples,  N.  Y.,  1916,  v.  3,  pp.  176-183,  12  pi. 
Amar,  J.     La  reeducation  professionnelle  des  mutiles  de  guerre.     Paris,  1917, 

P.  Renouard,  33  p.,  8". 
Amelia,  A.   C.  L.     Contribution  a  I'etude  des  complications  cardiovasculaires 

mentales  de  la  meningite  cerebrospinale  de  I'adulte.  Theses  de  Paris,  1915- 

1916,  v.  13. 

Amenitski,  D.  A.     The  insane  at   the  front.     Sovrem.  Psikhiat.,  Mosk.,  1915, 

■v'-  9.  PP-  325-333- 
Ancherson,  Maria.     (Psychosis  following  gunshot  wound  of  the  brain.)     Ugeskr. 

f.  Laeger,  Kbenh.,  191 7,  v.  79,  pp.  1039-1046. 
Anderson,  H.  M.  and  Noel,  H.  L.  C.     Case  of  shrapnel  injury  to  right  parietal 

cortex,  showing  paresis  of  left  lower  extremity,  together  with  cortical  sensory 

loss  and  thalamic  over-response.     Lancet,  Lon.,  1916,  i,  79. 
Andre-Thomas.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du 

crane  —  par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  473. 
Andre-Thomas.     Le  tonus  du  poignet  dans  la  paralysie  du  nerf  cubital.     Paris 

med.,  1917,  No.  49,  pp.  473-476.  _  _  _         j  -     -     ,  . 

Angelucci,  A.     La  protezione  degli  occhi  del  soldati  e  la  neducazione  dei  ciechi 

di  guerra.     Arch,  di  ottal.,  Napoli,  1916,  v.  23,  pp.  177-205. 
Anglade.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  crS.ne  —  par 

P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  p.  471. 
Ankle-jerk.  ..  Brit.  M.  J.,  Lond.,  1917,  i,  p.  556. 
Anton,  G.    Uber  psychische  Folgen  von  Kopfverletzungen  mit  und  ohne  Gehirn- 

erschutterung.     Psychiat.-neurol.  Wchnschr.  Halle  a.  S.,  1914-1915,  v.  16, 

PP-  365-370. 


BIBLIOGRAPHY  907 

Anton,  G.     Geistige  Wechselwirkung  im  menschlichen  Verkehr  und  Psychologic 

der  Masse.  Neurol.  Centralbl.,  37,  Nr.  12,  1918. 
Antonini,    G.      (Mental   symptoms  of  returning  disabled   soldiers.)      Pensiero 

med.,  Milano,  1915,  v.  5,  No.  50. 
A  propos  d'alcoolisme.     J.  de  med.  et  chir.  prat.,  Par.,  1916,  v.  87,  pp.  149-153. 
Arinstein,  L.  S.     (Neuropathological  observations  on  those  suffering  from  wind 

contusion.)  Psikhiat.  Gaz.,  Petrogr.,  1915,  v.  2,  pp.  85-88. 
Arinstein,  L.  S.     (Hysteria  and  organic  troubles  of  commotional  origin.)     Novoye 

V.  Med.,  Petrog.,  191 5,  v.  9,  No.  9  and  10. 
Arinstein,  L.  S.     (War  and  psychiatry.)     Russk.  Vrach,  Petrogr.,  1916,  v.  15, 

P-  950. 
Armstrong- Jones,  R.     Psychology  of  fear.     Effects  of  panic  fear  in  wartime. 

Hospital,  Lon.,  191 7,  Ixi,  493. 
Armstrong- Jones,  R.     Pv.elation  of  alcohol  to  mental  states,  particularly  in  regard 

to  the  war.     Practitioner,  1918,  c,  201. 
Armstrong- Jones,  R.     Mental  states  and  the  war;  in  particular  the  psychological 

effect  of  fear.     St.  Barth.  Hosp.  J.,  Lond.,  1916-1917,  v.  24,  pp.  95-103. 
Arnoux,     La  mort  par  decompression.     La  Nature,  18  Dec,  1915. 
Ascarelli,  A.     Una  nuova  forma  di  autolesione  (noduli  sclerotici  sottocutanei  da 

iniezione  di  so  stanze  inassorbibili).     Policlin.,  Roma,  19 17,  xxiv,  sez.  prat., 

1407-1410. 
Aschaffenburg,    G.     Uber    das    Zusammenvorkommen    organischer    und    nicht 

organischer   Nervenstorungen.     Neurol.    Central  bl.,    Leipz.,    191 5,   v.   34, 

pp.  926-928. 
Aschaffenburg,  G.     Winke  zur  Beurteilung  von  nerven-  und  psychisch-nervosen 

Erkrankungen.     Miinchen.  Med.  Wchnschr.  1915,  v.  622,  pp.  931-932. 
Aschaffenburg,    G.     Lokalisierte    und    allgemeine    Ausfallserscheinungen    nach 

Hirnverletzung.     Die   Methode  zur  Feststellung  und  ihre   Bedeutung  fiir 

die  soziale  Brauchbarkeit  der  Geschadigten.     Berl.   klin.  Wchnschr.  191 6, 

V.  53,  P-  127. 
Ash,   Edwin  Lancelot.     Nerves  in   war-time.     Lond.,    1914,   Mills  and   Boon. 

126  p.,  80. 
AstvatSturoff,  M.  L.     (Critique  of  the  study  of  reflex  epilepsy,  based  on  observa- 
tions on  wounded.)     Psikhiat.  Gas.,  Petrogr.,  1916,  v.  3,  pp.  185-190. 
Athanassio-Benisty,  Mme.     Formes  cliniques  des  nerfs.     Paris,   191 7,  Masson 

and  Cie.,  12°;   also  transl.  Engl,  in  Medical  and  Surgical  Therapy,  D.  Apple- 
ton,  1918;  and  in  Military  Med.  Manuals,  Univ.  Lond.  Press,  1918.* 
Aubaret.     L'hemeralopie  des  tranchees.     Bull.  Acad,  de  med..  Par.,  1917,  v.  77, 

p.  552. 
Aubertin.     Les  tachycardies  de  guerre.     Presse  m6d.,  24  Jan.,  1918. 
Audibert,  Victor.     La  simulation  dans  I'armee.     Paris  med.,   1916,  v.   19,  pp. 

103-106. 
Auer,  E.  M.     Phenomena  resultant  upon  fatigue  and  shock  of  the  central  ner- 
vous system  observed  at  the  front  in  France.     Med.  Rec,  N.  Y.,  1916,  v.  89, 

pp.  641—644. 
Auer,  E.  M.     Some  of  the  nervous  and  mental  conditions  arising  in  the  praeent 

war.     Mental  Hyg.,  Concord,  N.  H.,  1917,  i.  383-388. 
Auerbach,  F.    Der  Nachweis  der  Simulation  von  Schwerhorigkeit  mittels  einfacher 

Gehorpriifung.     Deutsche  med.  Wchnschr.,  1916,  v.  52,  pp.  1600-1601. 
Auerbach,  F.    Zur  Erkennung  der  Simulation  von  Schwerhorigkeit  und  Taubheit. 

Deutsche  mil.  arztl.  Ztschr.,  Bed.,  1917,  46,  412-17. 
Axenfeld,     T.     Hemianopische     Gesichtsfeldstorungen     nach     Schadelschussen. 

Klin.  Monatsbl.  Augenh.,  Stuttg.,  1915,  n.  F.,  v.  20,  pp.  126-143. 
Axhausen.     Die  Behandlung  der  Schadelschusse.     Die  Behandlung  von  I^iegs- 

verletzungen  und  Kriegskrankheiten  in  den  Heimatlazaretten.     Erster  Teil, 

p.  128.     Jena;   Fischer;    1915. 
Babcock,  H.  L.     Barany  tests  as  applied  to  aviators.     Bos.  M.  and  S.  J  ,  1917, 

clxxvii,  840. 
Babinoff,  Y.  K.     (Characteristics  of  diseases  of  the  nervous  system  durmg  the 

present  war.)     Morsk.  Vrech.,  Petrogr.,  1915.  PP-  503-5I4- 

*  These  translations  from  Masson's  Collection  Horizon  are  appearing  from 
time  to  time  and  not  always  mentioned  in  the  body  of  the  bibliography. 


9o8 


BIBLIOGRAPHY 


Babinski,  J.     De  la  paralysie  radiale  due  a  la  compression  du  nerf  par  des  be" 

quilles  (Association  organo-hysterique.)     Rev.  neurol.,  1914-15,  v.  22,  pp. 

408-409. 
Babinski,   J.     Lesion  spinale  par  eclatement  d'obus  a  proximite  sans  blessure 

ni  contusion.     Rev.  neurol.,  Par.,  1914-15,  v.  22,  pp.  581-583. 
Babinski,  J.     Les  caracteres  des  troubles  moteurs  (paralysies,  contractures,  etc.), 

dits  "  fonctionnels  "  et  la  conduitea  tenir  a  leur  egard.     Rev.  neurol..  Par., 

1916,  V.  23,  pp.  404;  52I-534-.  ^ 
Babinski,    J.     Reformes,    incapacites,    gratifications   dans    les    nevroses.     Rev. 

neurol..  Par.,  1916,  v.  23,  pp.  753-756. 
Babinski,  J.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  cr^ne 

—  par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  464. 
Babinski,  J.  et  Froment,  J.     Contributions  a  I'etude  des  troubles  ner\-eux  d'ordre 

reflexe.     Examen  pendant  I'anesthesie  chloroformique.     Rev.  neurol..  Par., 

1914-15,  V.  22,  pp.  925-933- 
Babinski  et  Froment,  J.     Sur  une  forme  de  contracture  organique  d'origine  peri- 

pherique  et  sans  exaggeration  des  reflexes.     Rev.   neurol.,   Par.,    1914-15, 

V.  22^,  p.  1276. 
Babinski,  J.  et  Froment,  J.     Les  modifications  des  reflexes  tendineux  pendant 

le  sommeil  chloroformique  et  leur  valeur  en  semiologie.     Lyon  Med.,  1915, 

V.   124,  pp.  347-361.     Also,  Bull.  Acad,  de  Med.,  Par.,   1915,  v.  74,  pp. 

439-452. 
Babinski,  J.  and  Froment,  J.     Hysteria  or  Pithiatism  and  P^eflex  Nervous  Dis- 
orders.    Military  Medical  Manuals,  Univ.  of  London  Press,  1918. 
Babinski,   J.   and  Froment,   J.     Service  de  neurologic   militarise  de  la   Pitie. 

Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  638-645. 
Babinski,   J.   et  Froment,   J.     Troubles  nerveux  d'ordre  reflexe  ou  syndrome 

d'immobilisation.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  914-918. 
Babinski,  J.  et  Froment,  J.     Abolition  du  reflexe  cutane  plantaire,  anesthesie, 

associees  a  des  troubles  vaso  moteurs  et  a  I'hypothermie  d'ordre  reflexe. 

Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  918-921. 
Babinski,  J.  et  Froment,  J.     Paralysie  et  hypotonic  reflexes  avec  surexcitabillte 

mecanique,  voltaique  et  faradique  des  muscles.     Bull.  Acad,  de  med.,  Par., 

1916,  p.  40. 
Babinski,  J.  et  Froment,  J.     Contractures  et  paralysies  traumatiques  d'ordre 

reflexe.     Presse  med..  Par.,  1916,  v.  24,  pp.  81-83. 
Babinski,  J.  et  Froment,  J.     Troubles  physiopathiques  d'ordre  reflexe.  Associa- 
tion avec  I'hysterie.     Evolution  de  mesures  medico-militaires.     Presse  Med., 

Par.,  1917,  v.  25,  pp.  385-386. 
Babinski,  J.  et  Froment,  J.     Hysteric,  pithiatisme  et  troubles  nerveux  d'ordre 

reflexe  en  neurologic  de  guerre.    Paris,  1916,  Massonand  Cic,  12°;  alsotransl. 

Engl,  in  Medical  and  Surgica'  Therapy,  D.  Appleton,  1918,  and  in  Military 

Med.  Manuals,  Univ.  London  Press,  1917. 
Babinski  et  Froment,  J.     A  propos  dc  la  communication  de  Roussy  et  Boisscau 

sur  le  pronostic  et  le  traitement  des  troubles  physiopathiques.     Rev.  neurol., 

Par.,  1917,  V.  24,  pp.  527-537- 
Babinski,  J.,  Froment,  J.,  et  Heitz,  J.     Des  troubles  vasomoteurs  et  thermiques 

dans  les  paralysies  et  les  contractures  d'ordre  reflexe.     Ann.  de  Med.,  Par., 

1916,  V.  3,  pp.  461-497. 
Babonneix  et  Celos.     Deux  cas  dc  goitre  exophtalmique  survenus  a  la  suite 

d'une  commotion  nerveuse.     Bull,  et  mem.  Soc.  med.  d.  hop.  dc  Par.,  1917, 

V.  33.  PP-  738-739- 
Babonneix,  L.  et  David,  H.     Traumatismes  cerebraux  et  syphilis.     Rev.  neurol., 

Par.,  1917,  V.  23,  pp.  277-281. 
Babonneix    et    David.     Monoplegie    hysterique    de   membre  superieur   gauche 

durant  depuis  deux  ans  et  gueri  en  deux  jours  par  la  suggestion.     J.  de  med. 

et  de  chir.  prat..  Par.,  1917,  v.  88,  Oct.  10. 
Bailey,  Pearce.     Neuropsychiatry  and  the  mobilization.     N.  Y.   Med.     Jour., 

1918,  cvii,  794. 
Bailey,  Pearce.      The  care  of  disabled  returned  soldiers.      Pacific  M.  J.,  San 

Francisco,  1917,  Ix,  608-615. 
Bailey,  Pearce.     The  care  of  disabled  returned  soldiers.     Mental  Hyg.,  Concord, 

N.  H.,  1917,  V.  I,  pp.  345-353- 


BIBLIOGRAPHY  9O9 

Bailey,  Pearce.     Psychiatry  and  the  army.     Harper's  monthly  mag.,  1917,  v 

135,  PP-  251-257- 
Bailey,  Pearce.      War  and  mental  diseases.      Am.  Jour.  Pub.  Health,    1918 

viii,  I. 
Baldi,  Felice.     Le  subconscient  dans  la  genese  des  phenomenes  traumato-nevro- 

siques.     Contribution  a  la  connaissance  de  la  nevrose  traumatique.     Annal 

di  Neurologia,  an  XXXII,  fasc.  4,  pp.  147-178,  1914. 
Ballard,   E.   Fryer.     An,  epitome  of  mental  disorders.      191 7,   Blakiston,  pp 

145-165. 
Ballet,  Gilbert.      Oedeme  blanc  associe  aux  contractures  d'origine  psychique 

Rev.  neurol..  Par.,  1914-15,  v.  22^,  pp.  705-707. 
Ballet,  G.     Bourdonnements  et  sifflements  d'oreille  dus  a  un  trouble  du  repre- 
sentation mentale.     Rev.  neurol..  Par.,  1914-15,  v.  22^  pp.  707-708. 
Ballet,  G.     Syndrome  de  Brown-Sequard  par  suite  de  commotion  par  eclatement 

d'obus,  sans  plaie  exterieure  (hematomyelie  vraisemblable) .    Rev.  neurol., 

Par.,  1914-15,  V.  22^,  pp.  768-769. 
Ballet,   G.     Note  sur  la  relation  des  tremblements  et  des  etats  emotionnels. 

Rev.  neurol..  Par.  1914-15,  v.  22^,  pp.  934-936. 
Ballet,  G.     L'insomnie  a  crises  intermittentes.     Presse  med.  Par.,  1916,  v.  24, 

PP-  73-74- 
Ballet,  G.     Persistance  des  contractures  d'origine  psychique  pendant  le  sommeil. 

Societe  de  Neurol.     29  juillet  1915. 
Ballet,  G.  et  Rogues  de  Fursac,  J.     Les  psychoses  "  commotionnelles."     Paris 

med.,  1916,  V.  19,  pp.  2-8. 
Ballet,  Sicard,  Dejerine,  etc.     Examens  ou  Ton  peut  suspecter  simulation  chez 

les  "  blesses  nerveux."     Rev.  neurol..  Par.,  1914-15,  v.  22,  pp.  1245-1247. 
Batinard,  W.     The  mechanics  of  convalescence:  methods  of  hastening  the  cure 

of  German  wounded  soldiers.     Scient.  Am.,  N.  Y.,  1915,  v.  112,  p.  404. 
Barat,  L.     Une  fugue  confusionnelle  en  temps  de  guerre.  J.  de  psychoL,  norm. 

et  path.,  Par.,  1914,  v.  2,  pp.  455-463. 
Barker,  L.  F.     War  and  the  nervous  system.     J.  Nerv.  and  Ment.  Dis.,  N.  Y., 

1916,  V.  44,  pp.  i-io. 
Earr,    J.,   Sir.     The   "Soldier's   Heart"   and   its  relation  to  thyroldism.  Brit. 

Med.  Jour.,  1916,  i,  544. 
Barron,  Netterville.     Physical  training  with  especial  reference  to  the  training  of 

convalescents.     J.  Roy.  Army  Med.  Corps,  Lond.,  1916,  v.  27,  pp.  460-476. 
Barth,  E.     Ueber  organische  und  funktionelle   Kehlkopfstorungen  bei  Kriegs- 

verletzungen.     Berl.  klin.  Wchschr.,  1916,  No.  5,  pp.  120-121. 
Basset,  A.     Plaies  des  nerfs  des  membres  par  projectiles  de  guerre.     Rev.  de 

Chir.,  1916,  li,  609. 
Batten,  F.  E.     Some  functional  nervous  affections  produced  by  the  war.     Quart. 

J.  Med.,  Oxford,  1915-1916,  ii,  pp.  13-38. 
Batten,  F.  E.     Two  cases  of  post-central  injury  of  cortex  shown  for  the  purpose 

of  eliciting  evidence  on  —  (i)  the  appreciation  of  vibration,  (ii)   Recovery, 

(iii)  Segmental  Representation  of  the  Cortex.     Proc.  Roy.  Soc.  Med.,  Lond., 

1915-16,  V.  9  (neurol.  sect.),  pp.  67-68. 
Baudisson  and  Marie  (A.).     Sur  la  spondylotherapie  des  troubles  astheniques  et 

vasomoteurs  post-traumatiques  ou  commotionnels.     Comp.  rend.  Acad.  d. 

sc.  Par.,  191 7,  clxv,  479. 
Bauer,    J.     Kombinationen    organischer    mit    funktionellen    Nervenstorungen. 

Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  175-176. 
I    aer,    J.     Einige   Bemerkungen   iiber   die    Beurteilung   und    Behandlung   der 

Kriegsneurosen.     Wien.  klin.  Wchschr.,  1916,  v.  29,  pp.  951-953- 
Bauer,  J.     Der  Baranysche  Zeigeversuch  und  andere  zerebellare  Symptome  bei 

traumatischen  Neurosen.      Wien.   klin.   Wchschr.,   1916,  v.  29,  pp.   1136- 

1144-  .  , 

Batimel,  J.     La  ponction  lombaire  dans  les  commotions  nerveuses  et  les  trau- 

matismes  du  cr^ne  par  projectiles  de  guerre.     Lyon  chirurg.,  1915,  v.  12, 

pp.  271-292.  „  ,   ^    ., 

Baumel,  J.  et  Lardennois,  G.     Diplegie  faciale.     N.  iconog.  de  la  Salpetnere, 

Par.,  1916-17,  No.  4,  pp.  272-381.  ,    ,      ,        T  ^ 

Bayliss,  Wm.  M.      Inti-avenous  injection  m  wound  shock.      Longmans,  Oreen 

&  Co.,  1918. 


910 


BIBLIOGRAPHY 


Bayliss,  W.  M.     On   the  origin  of   electro-currents  led  off   from  the   human 

body,    especially   in   relation   to    "  Nerve-leaks."      Proc.    Roy.    Soc.  Med., 

Lond.,  1917  (sect,  of  electro-therap.),  v.  10,  No.  7,  p.  11. 
Beaton,  T.     Some  Observations  on  Mental  Conditions  among  a  Ship's  Company 

in  War-time.     J.  Roy.  Nav.  M.  Serv.,  Lond.,  1916,  No.  i;   pp.  447-452. 
Beauchant,  R.  Morichau.     Le  signe  de  I'atrophie  musculaire  et  de  I'hyperes- 

thesie  profonde  dans  la  tuberculose  fibreuse  du  sommet.  Paris  Med.,  1916 

(Part.  Med.),  v.  19,  pp.  589-592. 
Bechterew,  W.  M.     (War  and  psychoses.)     Novoye  v.  Med.,  Petrogr.,  1915,  v. 

9,  No.  7,  No.  8. 
Beck,    O.     Das    Romberg-Phanomen   bei   traumatischer   Neurose    (Schrapnell- 

neurose).     Monatschr  f.  Ohrenhk.,  Berl.  u.  Wien.,  1915,  v.  49,  pp.  209-210. 
Becker,  Wem.  H.     Kriegspsychosen.   Psychiat.-neurol.  Wchschr.,   1914-15,  v. 

16,  pp.  295-298.  .  .,     J         ,  .  .  ,      .  , 

Belenki.     Les  symptomes  sensitifs  dans  les  sections  anatomiques  et  physiolo- 

giques  des  nerfs  peripheriques.     Presse  Med.  Feb.  17,  191 6. 
Bellin  et  Vemet.     Sur  une  forme  nouvelle  de  syndrome  bulbaire  inferieur  avec 

ataxie  du  larynx.     Bull,  et  mem.  Soc.  med.  d'.  hop.  de  Par.,  1917,  v.  33, 

pp.  83-89.  ^  ,...,.. 

Benassi,  G.     Malattie  vere  e  malattie  simulate  in  rapporto  al  servizio  militaire. 

Quaderni  di  med.  leg.,  Milano,  1917.  i.  196;   217-252. 
Benedikt.     Der  Epileptiker  bei  der  Musterung.      Wien.  klin.  Wchschr.,  1915, 

V.  28,  pp.  592-593- 
Benedikt.     Der  Epileptiker  bei  der  Musterung.     Med.  klin.,    Berl.  u.  \Men., 

1915,  V.  2^,  p.  762. 
Benisty-Athanassio.     Clinical    Forms    of    Nerve    Lesions.     Military    Medical 

Manuals,  Univ.  of  London  Press,  191 8. 
Benisty-Athanassio.     The  Treatment  and  Repair  of  Nerve  Lesions.     Military 

Medical  Manuals,  Univ.  of  London  Press,  1918. 
Benisty-Athanassio.     Traitement  et  restoration  de  lesions  des  nerfs.      Collec- 
tion Horizon,  Masson  et  Cie,  Paris,  191 7. 
Bennati,  Nando.     La  etiologia  determinante  nella  nevrosi  traumatica  di  guerra. 

Rev.  sper.  di  freniat.,  Reggio-Emilia,  1916,  v.  42,  pp.  49-84. 
Bennett,  Wm.  L.     Psychasthenia.     J.  Roy  Army  Med.  Corps,  Lond.,  191 7,  v. 

28,  p.  614. 
Benon,R.     Au  sujet  des  nevrosestraumatiques,  Reunion  de  la  11°  armee  I7juillet, 

1915- 
Benon,  R.     Les  maladies  mentales  et  nerveuses  et  la  guerre.     Rev.   neurol.. 

Par.,  1916,  4.     23,  pp.  210-215. 
Benon,  R.     Les  maladies  mentales  et  nerv-euses  et  la  pratique  des  reformes  No.  i. 

Rev.  neurol.,  Par.,  191 7,  v.  24,  pp.  306-309. 
Benon,  R.     La  guerre  et  les  pensions  pour  maladies  mentales  et  nerveuse.     Rev. 

neurol.,  Par.,  1916,  v.  24,  pp.  320-323. 
Berard.     Alcoolisme  et  anesthesie.     Lyon  Med.,  1917,  v.  126,  pp.  282-285. 
Bergonzoli,   G.     Stati  ansiosi   nelle   malattie   mentali.     Voghers:  Art   Grafiche, 

1915,  pp.  186. 
Berlung,  Richard.     Organische  Erkrankungen  mit  hysterlsche  Pseudodemenz. 

Monatschr.  f.  Psychiat.  u.  Neurol.,  Berl.,  1916,  v.  39,  No.  5;   p.  268. 
Bemhard,   L.   I.     Business  organization  of  the  workshops  connected  with  the 

Royal  Orthopedic  Reserve  Hospital  at  Niirnberg.     Am.  J.  Care  Cripples, 

N.  Y.,  191 7,  V.  4,  pp.  197-200. 
Bernheim.     Le  courage.      Rev.  gen.  de  clin.  et  de  therap.,  Par.,  1915,  v.  29, 

pp.  495-498. 
Bernheim.     Amaurose   simulee  et    amaurose   psychique.     Simulation  et  auto- 
suggestion.    Rev.  gen.  de  clin.  et  de  therap..  Par.,  1916,  v.  30,  pp.  609-610. 
Bernheim.     Psychonevroses,  psychotherapie.     Rev.  gen.  de  clin.  et  de  therap., 

Par.,  1916,  V.  30,  pp.  739-741. 
Bernheim.     Psychonevroses  rebelles.     Procedes  divers  associes  a  la  suggestion. 

Rev.  gen.  de  clin.  et  de  therap.,  Par.,  1916,  v.  30,  pp.  820-823. 
Bernheim.      Nevroses,  psychonevroses,  hysterie.      Progres  med.,  Par.,  1917,  v. 

43-  PP-  355-357-  ,      .  •  „     .       r^      , 

Bernheim.     Y-a-t-il  des  aphasies  sensonelles?  —  Surdite  et  cecite  verbales.     Kev, 
gen.  de  clin,  et  de  therap.,  Par.,  191 7,  v.  31,  pp.  518-520. 


BIBLIOGRAPHY  9 II 

Berruyer.     Un  cas  de  surdi-mutite  simulee  datant  de  cinq  mois.    Caducee,  Par., 

1916,  V.  16,  pp.  129-130. 
Bemiyer.     Surdite  de  guerre.     Reeducation  de  I'ouie.     Caducee,  Par.,  1917,  v. 

17,  pp.  17-21;   also  pp.  1-3. 
Berruyer.     Un  cas  de  surdi-mutite  simulee  datant  de  cinq  mois.     J.  de  Med.  de 

Par.,  191 7,  V.  36,  p.  34. 
Bertein  et  Rimmer.     Les  premieres  heures  du  blesse  de  guerre  du  trou  d'obus  au 

poste  de  secours.     Collection  Horizon,  Masson  et  Cie,  1918. 
Besson.     An  sujet  des  nevroses  traumatiques.     Rev.  gen.  de  clin.  et  de  therap., 

Par.,  1915,  y.  29,  p.  527. 
Besson.     Au  sujet  des  nevroses  traumatiques.     Presse  Med.,  Par.,  1915,  v.  23, 

P-  316... 
Best,   F.     Uber  Nachtblindheit  im  Felde.     Munchen.  Med.  Wchschr.,  1915,  v. 

622,  pp.  1121-1124. 

Beutenmuller.     Uber   Nachtblindheit   im   Felde.     Munchen    med.    Wchnschr., 
191 5,  v.  622,  p.  1207. 

Beyer,  Ernest.     Uber  die  Bedeutung  der  Rentenhohe  bei  der  Entstehung  der 

Rentenneurose.     Aerztl.  Sachverst.  Ztg.,  1915,  v.  21,  pp.  242-244. 
Bianchi,  V.     Le  nevrosi  nell'  esercito  in  rapporto  alia  guerra.     Med.  e  chir.  d. 

med.  prat.,  Napoli,  1917,  v.  i,  No.  5,  pp.  1-16. 
Bianchi,  V.     Le  nevrosi  nell'  esercito  in  rapporto  alia  guerra.     Ann.  di.  nevrol., 

Napoli,  1917,  V.  34,  pp.  1-20. 
Bianchi,  V.     Neuropsichiatria  di  guerra.     Ann.  di  nevrol.,  Napoli,  1917,  v.  34, 

pp.  21-38.^ 
Bickel,    Heinrich.     Zur    pathogenese  der  im   Krieg  auftretenden   psychischen 

Storungen.     Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  117-121. 
Bielschowsky,  A.     Sehstorungen  im  Kriege  ohne  objektiven  Augenbefund,  Miin- 

chen  med.  Wchnschr.,  1914,  v.  61,  pp.  2443-2445. 
Bielschowsky,  A.     Die  Forderung  des  akademischen  Blindenbildungswesens  im 

Kriege.     Stuttgart,  Enke,  1917. 
Bikhovski,  S.     (Diagnosis  of  epilepsy  in  the  clinic  and  in  army  medical  practice.) 

Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  300-306. 
Bilancioni,  G.     Di  un  metodo  sicuro  per  svelare  la  simulazione  della  sordita 

bilaterale.     Arch.  ital.  di  otol.  (etc.),  Torino,  1916,  xxvii,  516-524.     Also: 

Policlin,  Roma,  1917,  xxiv,  sez.  prat.,  743-745. 
Brng,  Robert.     Pathogenese,  Prophylaxe  und  Begutachtung  psychoneurotischer 

Unfallfolgen.     Deutsche   med.   Wchnschr.,    Bed.   u.    Leipz.,    1915,   v.   4.1^, 

pp.  903. 
Binswanger,  Otto.     Kriegsneurologische  Krankenvorstellungen.     Munchen  med. 

Wchnschr.,  191 5,  v.  631,  p.  1651. 
Binswanger,     Otto.     Hystero-somatische     Krankheitsserscheinungen     bei     der 

Kriegshysterie.     Monatschr.  f.  Psychiat.  u.  Neurol.,  Berl.,  1915,  v.  38,  pp. 

1-60. 
Binswanger,  Otto.     Uber  Kommotionspsychosen  und  Verwandtes.     Cor.  Bl.,  f. 

Schweiz.  Aerzte.,  1917,  v.  47,  pp.  1401-1412. 
Bird,  Charles.     From  home  to  the  charge;   a  psychological  study  of  the  soldier. 

Am.  J.  Psychol.,  1917,  v.  28,  pp.  315-348. 
Birkett.     Special  discussion  on  warfare  injuries  and  neuroses.     Proc.  Roy.  Soc. 

Med.,  Lond.,  1917,  v.  10  (sec.  Otol.),  p.  90. 
Bimbaiim,  Karl.     Geistesstorungen  im  Kriege.     Umschau,  1914,  No.  43. 
Bimbaum,  Karl.     Kriegsneurosen  und  psychosen  auf  Grund  der  gegenwiirtigen 

Kriegsbeobachtungen.     Ztschr.  f.  d.  ges.  neurol.  u.  psychiat.,  Berl.  u.  Leipz., 

1914-1915,  v.  II  (Ref.),  pp.  321-369- 
Birch-Hirschfeld.     Ueber   Nachtblindheit   im   Kriege.     Deutsche   med.   Wchn- 
schr., Leipz.  u.  Berl.,  1916,  v.  42,  p.  1306. 
Bittorf,  A.     Zur  Behandlung  der  nach  Granatexplosionen  auftrefenden  Neurosen. 

Med.  klin.,  Berl.  u.  Wien,  1915,  v.  ii^,  pp.  897-898. 
Bittorf,  A.     Zur  Behandlung  der  nach  Granatexplosionen  auftretenden  Neurosen. 

Munchen.  med.  Woch.,  1915,  v.  62,  pp.  1029-1031. 
Black.     Treatment  by  physical  methods  of  mental  disabilities  induced  by  the 

war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-1918,  v.  10  (sect.  Balneol.),  pp. 

24-30. 


912  BIBLIOGRAPHY 

Blanc,  Jean.     La  dysthyroidi^,  facteur  de  nevroses.     Le  reflexe  ocuJocardiaque 

regulateur  de  I'opotherapie  thyroidienne.     Progres  med.,  Par.,  191 7,  No.  12, 

PP-  95-98. 
Blassig.     Funktionelle  Stimmbandlahmung.     Miinchen  med.  Wchnschr.,  1915, 

V.  62,  p.  835. 
Blin  and  Kernels.     Un  cas  de  paralysie  generale  spinale  anterieure.     Caducee, 

Par.,  1916,  V.  16,  pp.  111-113. 
Blum,  E.     De  la  simulation:    Etude  des  qualites  que  doit  posseder  le  medecin 

militaire  expert.     Gaz.  hebd.  d.  sc.  med.  de  Bordeaux,  1916,  27  aout,  pp.  124- 

125,  also  1916,  10  Sept.,  pp.  129-132. 
Bliun,  E.     De  la  simulation  "  La  carotte."     J.  de  med.  de  Bordeaux,  1915-16,  v. 

45.  PP-  274-280. 
Blum,  E.  and  Dumer,  G.     De  la  simulation;   ses  causes,  son  traitement.     Gaz. 

hebd.  d.  sc.  med.  d.  Bordeaux,  1916,  xxxvii,  76;   84;  93. 
Blimi,  E.     La  dissimulation.     Gaz.  hebd.  d.  sc.  med.  de  Bordeaux,  1917,  v.  38, 

pp.  57-61,  and  pp.  67-68. 
Blumenau,  L.  V.     (Organization  of  medical  aid  to  neurotic  soldiers  at  the  front.) 

Psikhiat.  Gaz.,  Petrogr.,  1915,  v.  2,  p.  5. 
Boeckel,  J.     A  quels  accidents  tardifs  sont  exposes  les  blesses  du  crane?     Bull,  et 

mem.  Soc.  de  chir.  de  Par.,  1916,  v.  42,  pp.  1575-1593. 
Boeckel,  J.     Les  blessures  du  crane.     Lyon  chir.,  19 16,  13,  pp.  903-911. 
Boisseau,  J.     Quelques  exemples  de  differents  modes  de  suggestion  determinant 

des  accidents  hysteriques.     Presse  med.,  Par.,  1915,  v.  23,  pp.  47-48. 
Bonhoeffer,      K.  Die  Dienstbeschadigungsfrage  in  der  Psychopathologie.     Die 

niilitararztliche     Sachsverstandigentatigkeit   auf   dem   Gebiete  des   Ersatz- 

wesens  und  der  militarischen  Versorgung.     Erste  Teil,  pp.  86-115.     Jena, 

Fischer,  191 7. 
Bonhoeffer,  K.     Psychiatrisches  zum  Kriege.     Monatschr.  f.  Psychiat.  un  Neu- 
rol., Bed.,  1914,  V.  36,  pp.  435-448. 
Bonhoeffer,  K.     Psychiatrie  und  Krieg.     Deutsche  med.  Wchnschr.,  1914,  v.  40, 

pp.  1777-1779. 
Bonhoeffer,  K.     Die  Dienstbeschadigungsfrage  in  der  Psychopathologie.     Mil. 

artzl.     Sachvest-Tatigk.,  Jena  1917,  i,  86-114. 
Bonhoeffer,  K.     Ueber  Falle  von  hysterischer  Granatexplosionslahmung.     Berl. 

klin.  Wchnschr.,  1915,  Hi,  166-168. 
Bonhoeffer,   K.     Uber  die  Abnahme   des   Alkoholismus   wiihrend   des   Krieges. 

Monatschr.  f.  Psychiat.  u.  Neurolog.,  191 7,  41,  382-5. 
Bonhoeffer,   K.     Die   Differentialdiagnose   der   Hysteric   und   psychopathischen 

Konstitution  gegeniiber  der  Hebephrenic  im  Felde.     Med.   Klin.,  Berl.  u. 

Wien.,  1915,  V.  11,  pp.  877-881. 
Bonhoeffer,    K.     Erfahrungen    iiber   Epilepsie   und   Verwandtes   im   Feldziige. 

Monatschr.  f.  Psychiat.  u.  Neurol.,  Berl.,  1915,  v.  38,  p.  61. 
Bonhoeffer,  K.     Hysterischer  Granatexplosionslahmung.     Berl.  klin.  Wchnschr., 

1915.  V.  52',  pp.  166-168. 
Bonhoeffer,   K.     Uber  meningeale  Scheincysten  am  Riickenmark.     Berl.  klin. 

Wchnschr.,  1915,  v.  52^,  pp.  1015-1018. 
Bonhoeffer,  K.     Psychiatrisches  zum  Krieg.     Ztschr.  f.  Artzl.     Fortbild.,  Jena, 

1915,  c.  12,  pp.  1-9. 

Bonhoeffer,  K.  Falle  von  sogenannter  Granatexplosionslahmung.  Neurol.  Cen- 
tralbl.,  Leipz.,  1915,  v.  34,  pp.  73-74- 

Bonhoeffer,  K.  Die  Bedeutung  der  Kriegsbeschadigungen  in  der  Psychopa- 
thologie unter  besonderer  Beriicksichtigung  der  D.-B.-Frage.  Med.  Klin., 
Berl.,  1916,  V.  12,  pp.  1301;   also  Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz., 

1916,  V.  42,  pp.  1466. 

Bonhoeffer,  K.  Erfahrungen  aus  dem  Kriege  iiber  die  Aetiologie  psychopathi- 
scher  Zustande.     Miinchen  med.  Wchnschr.,  1916,  v.  63,  pp.  1557-1558. 

Bonhoeffer,  K.  Falle  von  hysterischer  Granatexplosionslahmung.  Arch.  f. 
Psychiat.,  Berl.,  1916,  v.  56,  pp.  701-702. 

Bonhomme.  Un  cas  de  puerilisme  mental  post  commotionnel.  Ann.  med. 
psychol..  Par.,  191 7,  v.  73,  pp.  384-390. 

Bonhomme  et  Nordmann.  Caracteres  essentiels  de  la  commotion  cerebro- 
spinal.    Progres  med.,  Par.,  1916,  pp.  194-196. 


BIBLIOGRAPHY 


913 


Bonhomme    et   Nordmann.     Caracteres   essentiels   de   la   commotion   cerebro- 

spinale.     Ann.  med.  psychol.,  Par.,  1916-17,  v.  7,  pp.  530-540. 
Bonhomme  et  Nordmami.     Note  sur  deux  cas  de  dements  precoces  k  I'armee. 

Ann.  med.  psycho!.,  Par.,  1916-17,  v.  7,  pp.  546-549. 
Bonhomme  et  Nordmann.     Un  cas  d'hallucinose.     Ann.  med.  psychol.     Par. 

19 1 6-1 7,  V.J,  pp.  549-554. 
Bonnier,  P.     L'etat  de  guerre  et  les  pannes  nerveuses.     Compt.  rend.  Soc.  de 

Biol.,  Par.,  1916,  V.  75,  pp.  216-218;   Presse  med.,  Par.,  1916,  v.  24,  p.  140. 
Bonnier,  P.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  crine  — 

par  P.  Marie.     Rev.  neurol..  Par.,  191 6,  v.  29,  pp.  5-6. 
Bonnus,  G.     La  radiotherapie  dans  les  affections  spasmodiques  de  la  moelle  par 

blessures  de  guerre.     Paris  med.,  1916,  (Part.  Med.),  v.  19,  pp.  32-35. 
Bonnus,  Chattier  et  Rose.     Resultats  de  la  radiotherapie  dans  les  traumatisme 

cranio-cerebraux.     Lyon  med.,  1917,  v.  126,  pp.  233-234. 
Bonola,  F.     La  sindrome  commozionale  da  scoppio  di  projettile.     Bull.  d.  sc.  med. 

di  Bologna,  1917,  9.  s.,  v,  282-288.     Also:   Gazz.  med.  lomb.,  Milano,  1917, 

Ixxiv,  189-192. 
Bonola,  F.     I   disturbi  psico-nervosi  dei  combattenti.     Quaderni  di  psichiat., 

Genova,  1917,  v.  4,  pp.  141-156. 
Bonola,  F.     Contributo  alio  studio  delle  psiconevrosi  di  guerra.    Gior.  di  med.  mil., 

Roma,  191 5,  Ixiii,  837-841. 
Bonola,   F.     (Psychoneuroses  of  War.     A  case  of  psychic  deafness.)     Gior.  di 

med.,  Mil.,  1915,  v.  63  (Nov.). 
Borchard,    A.     Spatapoplexien    nach    Gehirnschiissen    und    Schadelplastiken. 

Centralbl.  f.  Chir.,  Leipz.,  1917,  44,  650. 
Bordier,  H.,  et  Gerard,  M.     Ce  que  peut  donner  la  radiotherapie  dans  les  lesions 

nerveuses  par  blessures  de  guerre.     Presse  med.  Par.,  191 7,  v.  25,  pp.  453- 

455- 
Borishpolski,  Ye.  S.     (Role  of  the  motor  area  of  the  brain  cortex  in  the  develop- 
ment of  epileptic  attacks,  based  on  observations  on  wounded.)     Psikhiat. 

Gaz.,  Petrogr.,  1916,  v.  3,  p.  119. 
Borne.     De  la  reeducation  et  de  la  readaptation  au  travail  des  blesses  et  des 

mutiles  de  la  guerre.     Rev.  d'hyg.,  Par.,  1915,  v.  37,  p.  81;   p.  159. 
Borne.     De  I'assistance  et  de  la  readaptation  des  malades  de  la  guerre.     Rev. 

d'hyg..  Par.,  1915,  v._37,  pp.  833-849. 
Borne.     De  la  readaptation  et  de  la  reeducation  au  travail  des  blesses  et  des 

mutiles  de  la  guerre.     Paris  med.,  1915-16,  v.  17,  pp.  293-298. 
Borovikoff,  I.  V.     (Prisoners  and  those  under  test  for  insanity,  and  insane,  in  the 

psychiatric  ward   of   the   Riga  military  hospital.)     Voyenno-Med.   J.,  St. 

Petersb.,  1914,  ccxxxix,  med. -spec,  pt.,  221-240. 
Boschi,  G.     La  neuropsychiatrie  et  la  guerre.     Rev.  neurol..  Par.,  1917,  v.  24, 

P-  474.       ,      .  ,      .  .,        . 

Boschi,  G.     L  assistenza  femmile  nei  reparti  maschih  dei  manicomi  durante  la 

guerra.     Atti  Accad.  d.  sc.  med.  e  nat.  di  Ferrara  (1914-15),  1915-16,  Ixxxix, 

No.  2,  3-7. 
Boschi,  G.     (Provision  for  the  Care  of  War  Neuroses  and  Psychoses  in  France.) 

Gior.  di  med.,  Mil.,  1917,  V.  65,  Nov.  30. 
Bossi,  P.     II  padiglione  di  meccanoterapia  F.  Ponti.     Osp.  Maggiore,  Milano, 

1916,  2  s.,  V.  4,  pp.  I44-I53- 
Bostroem,  A.     Zur  Psychologic  u.  Klinik  der  psychogenen  Horstorungen.     Ztschr. 

f.  d.  ges.  Neurol,  u.     Psychiat,  40,  1918. 
Bott,  E.  A.     Rehabilitation  of  wounded  Canadian  soldiers.     Mod.  Hosp.,  191 7, 

ix,  365- 
Boucherot,  F.  M.  A.     Maladies  mentales  dans  I'armee  en  temps  de  guerre.    Theses 

de  Paris.,  1915-16,  No.  37,  v.  2. 
Bouquet,  Henri.     La  reeducation  des  mutiles  de  la  guerre.     Bull.  gen.  de  therap., 

Par.,  1916,  V.  85,  pp.  156-181;  pp.  193-213. 
Bouquet.     Deux  cas  de  tetanos  localise  tardif.     Bull.  gen.  de  therap.,  Par.,  1916, 

V.  168,  pp.  814-817. 
Bourgeois,  H.  and  Sourdille.     Otites  et  surdites  de  guerre.     Collection  Horizon, 

Masson  et  Cie,  Paris,  191 7. 
Bourgeois,  H.  and  Sourdille.     War  Otitis  and  War  Deafness.     Military  Medical 

Manuals,  Univ.  of  London  Press,  191S. 


914  BIBLIOGRAPHY 

Bourgeois,  A.     Traumatismes  graves  de  I'oeil  par  blessures  de  guerre  dans  lesions 
immediatement  apparentes.     Arch,  d'ophth.,  Par.,  1914-15,  v.  34,  pp.  766- 

769- 
Bounllon.     Comment  reeduquer  nos  invalides  de  la  guerre:  I'assistance  aux  es- 

tropies  et  aux  inutiles  en  Danemark,  Suede,  et  Norvege.     Collection  Horizon, 

Masson  et  Cie,  1916. 
Bourillon.     Functional   readaptation   and   professional   reeducation   of   the  dis- 
abled victims  of  the  war.     Amer.  Jour.  Care  for  Crip.,  1916,  iii,  23. 
Bourillon.     The  vocational  re-education  of  disabled  soldiers.     Mil.  Hosp.  Com. 

Canada,  Spec.  Bull.,  Ottawa,  1916,  pp.  77-89. 
Boven.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  crane  —  par 

P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  4-5. 
Boveri,  P.     Di  alcune  questioni  medico-legali  in  rapporto  alia  guerra;   le  nevrosi. 

Riv.  crit.  in  materia  di  infortuni  (etc.),  Roma,  1916,  v.  5,  pp.  33-35. 
Brackenbury,  H.  B.     Discharged  disabled  soldiers  and  sailors.     Brit.   M.  J., 

Lond.,  1917,  v.  2,  p.  437. 
Braquehaye.     Section  du  nerf  median  droit.     Suture  immediate  du  nerf.     Retour 

partiel  des  fonctions.     Reunion  med.  de  la  VI  armee,  Nov.-Dec.  1915. 
Brasch.     Herzneurosen  mit  Hauthyperasthesie.     Med.  klin.,  Berl.  u.  Wien.,  1915, 

V.  ii^,  pp.  627. 
Braunschweig.     Kurze  Mitteilungen  iiber  die  epidemische  Hemeralopie  im  Felde. 

Med.  Klin.,  Berl.  u.  Wien.,  1915,  v.  iii,  pp.  313-314. 
Bresler.     Schadel-  und  Gehirnverletzungen  (Bib.)  C.  Marhold,  Halle,  191 7. 
Briand,  Marcel.     Les  toxicomanes  et  la  mobilisation.     Presse  med.,  Par.,  19 14, 

V.  22,  pp.  751-752- 
Briand,  Marcel.     Les  fugueurs  a  I'armee.     Soc.  de  med.  leg.  de  France,  Bull., 

Par.,  1915,  V.  12,  pp.  42-63. 
Briand,  Marcel.     Les  comitiaux  a  I'armee.     Soc.  de  med.  leg.  de  France,     Bull., 

Par.,  1915,  V.  12,  pp.  196-202. 
Briand,  Marcel.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du 

crane  —  par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  470. 
Briand,  Marcel.     Troubles  organiques  d'origine  fonctionnelle  chez  les  militaires 

commotionnes.     Ann.  med.-psychol..  Par.,  191 7,  v.  73,  pp.  577-582. 
Briand,  Marcel  et  Delmas.      Sur  la  liquidation  des  indemnites  aux   militaires 

"  perseverateurs  "  atteints  de  troubles  fonctionnels  hysteriques.     Soc.  med. 

leg.  de  France,  Par.,  1917,  v.  14,  pp.  223-233. 
Briand  et  Haury.     Role  de  la  complicite  dans  la  simulation  ou  la  provocation  des 

maladies.     Soc.  de  med.  leg.  de  France,  Bull.,  Par.,  1916,  v.  13,  pp.  51-59. 
Briand  et  Kalt.     Maladies  simulees  et  maladies  provoquees  dans  I'armee.     Soc. 

de  med.  leg.  de  France,  Bull.,  Par.,  1917,  v.  14,  pp.  42-48. 
Briand,  Marcel  et  Philippe,  Jean.     L'audi-mutite  rebelle,  d'origine  emotionelle. 

Progres  Med.,  Par.,  1916,  No.  17,  pp.  145-148. 
Brickley,  C.  W.     Treatment  by  physical  methods  of  mental  disabilities  induced 

by  the  war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-1918,  v.  10  (sect.  Balneol.), 

PP-  36-37- 
Briggs,  L.  V.     A  plea  for  more  psychiatrists  and  neurologists  for  war  service. 

Proc.  Alienists  and  Neurol.  Am.,  Chicago,  1917,  v.  6,  p.  31. 
Broca,  Aug.     Troubles  locomoteurs  consecutifs  aux  plaies  de  guerre.     Collection 

Horizon,  Masson  et  Cie,  Paris,  1918. 
Broca,  A.  et  Ducsoquet.     La  prothese  des  amputes  en  chirurgie  de  guerre.     191 7, 

Paris,  Masson  and  Cie. 
Brock,  A.  J.     The  war  neurasthenic.     Lancet,  Lon.,  1918,  i,  436. 
Brock,  L.  G.     Reeducation  of  the  disabled.     Amer.  Jour.,  Care  for  Crip.,     191 7, 

iv,  19. 
Brocq.     Influence  de  la  guerre  sur  les  affections  cutanees.    Bull,  med.,  19 16,  No.  3. 
Brodman,  K.     Zur  Neurologic  der  Stirnhirnschusse.     Miinchen  med.  Wchnschr., 

191 5,  V.  62^,  p.  1 1 20. 
Brousses,  J.     Une  mecanotherapie  de  fortune  a  I'hopital  complementaire  No.  31 

de  Toulouse.     Arch,  de  med.  et  pharm.  mil..  Par.,  1914-15,  v.  64,  pp.  177-185. 
Brovchinski,  A.  V.     (Case  of  nervous  symptom  complex  due  to  wind  contusion.) 

Psikhiat.  Gaz.,  Petrogr.,  19 16,  pp.  237-240. 
Brovchinski,   A.   V.     (Paraplegia   in   atmospheric   contusion.)     Psikhiat.    Gaz., 

Petrogr.,  1916,  v.  3,  pp.  394-398. 


BIBLIOGRAPHY  915 

Brown,  H.  E.     Head,  abdominal  and  joint  injuries;    notes  on  cases.     Lancet, 

Lon.,  1916,  i,  1082. 
Brown,  Mabel  W.  and  Williams,  Frankwood  E.     Neuropsycliiatry  and  the  War, 

1918. 
Brown,  Mabel  W.  and  Williams,  F.  E.     Neuropsychiatry  and  the  War;  a  biblio- 
graphy with  abstracts.     Mental  Hyg.,  Concord,  N.  H.,  1917,  v.  i,  pp.  409-474. 
Brown,  William.     Shell  shock  without  visible  signs  of  injury.     Proc.  Roy.  Soc. 

Med.,  Lond.,  1915-1916  (sect.  Psychiat.),  pp.  3o'-32. 
Bruce,  Ninian.     The  Treatment  of  Functional  Blindness  and  Functional  Loss  of 

Voice.     Rev.  Neurol,  and  Psychiat.,  Edinb.,  1916,  v.  14,  pp.  195-198. 
Brunig,  F.     Ueber  grosse  lufthaltige  Gehirncyste  nach  Schussverletzung.     Bruns' 

Kriegschir.     Hefte  d.  Beitr.  z.  klin.  Chir.,  Tiibing.,  191 7,  107,  432. 
Bruns,   L.     Kriegsneurologische   Beobachtungen   und    Betrachtungen.     Neurol. 

Centralbl.,  Leipz.,  191 5,  v.  34,  pp.  12-15. 
Bucky.     Diathermia  in  den  Lazaretten.     Deut.  Med.  Woch.,  191 5,  xli,  467. 
Bulletins.     Federal  Board  for  Vocational  Education.       Nos.   i-io,   1917-1918. 

Washington  Government  Printing  Office. 
Bunnemann.     Zur  traumatische  Neurose  im  Kriege.     Neurol.  Centralbl.,  Leipz., 

191 57  V.  34,  pp.  888-898. 
Bunnemann.     Die   Neurosenfrage   und  das  biologische  Grundgesetz.     Neurol. 

Centralbl.,  Leipz.,  1916,  v.  35,  pp.  178-187. 
Bunse,  P.     Die  reaktiven   Dammerzustande  u.   verwandte  Storungen  in  ihrer 

Bedeutung  als  Kriegspsychosen.  Ztschr.  f.  d.  ges.  Neurol,  u  Psych.,  40,  1918. 
Burke,  Noel  H.  M.     Electrotherapy  in  Military  Hospitals.     Arch.  Radial,  and 

Elec,  Lond.,  1917,  Oct.,  pp.  130-135. 
Biuniston,  Hugh  S.     Notes  on  a  successful  case  of  treatment  by  suggestion.     J. 

Roy.  Nav.  M.  Serv.,  Lond.,  1917,  v.  3,  pp.  116-117. 
Burton-Fanning,  F.  W.     Neurasthenia  in  soldiers  of  the  home  forces.     Lancet, 

Lond.,  1917,  V.  I,  pp.  907-911. 
Burton-Fanning,  F.  W.     Neurasthenia  in  soldiers  of  the  home  forces.     Lancet, 

Lon.,  1917,  i,  907. 
Bury,  J.  S.     Distant  effects  of  rifle  bullets,  with  special  reference  to  the  spinal 

cord.     Brit.  Med.  Jour.,  1916,  ii,  212. 
Busacchi,  A.     Edemi  pseudo-traumatici  della  man.     Bull.  d.  sc.  med.  di  Bologna, 

1917,  9.  s.,  V.  345-355- 
Buscaino,  V.  M.  and  Coppola,  A.     Disturoi  mentale  m  tempo  di  guerra.     Riv.  di 

patol.  nerv.,  Firenze,  1916,  v.  21,  pp.  1-103;   also  pp.  135-182. 
Buschan,  Georg.     Uber  Kriegspsychosen.  Med.  Klin.,  Berl.  u.  Wien,  1914,  v. 

10-,  pp.  1588-1591. 
Butenko,  A.  A.     (The  War  and  Mental  Diseases  in  Women.)     Obozr.     Psikhiat., 

Neurol,  (etc.),  Petrogr.,  1914-1915,  v.  19,  pp.  521-542. 
Butt,  A.  P.     Destruction  of  the  spinal  cord  by  molecular  vibration.     Surg., 

Gynec.  and  Obst.,  Chicago,  19 15,  xx,  486. 
Buttersack.     Zur   Casuistik  der   Kriegsneurosen.     Med.   Cor.-Bl.   d.   wiirtemb. 

arztl.  Landesver.,  Stuttg.,  1916,  v.  86,  pp.  1-5. 
Buzzard,  E.  Farquhar.     "  Warfare  on  the  Brain."     Lancet,  Lond.,  1916,  ii,  pp. 

1095-1099. 
Call,  Annie  P.     Nerves  and  the  war,     1918. 
Calot,  F.     Orthopedie  de  guerre;    appareil  pour  fractures,  etc.     Paris,  1916,  A. 

Maloine  et  fils,  p.  100,  8°.  ... 

Cadenat,  F.  M.     Le  pronostic  des  fractures  du  crane  par  projectiles.     Paris  med., 

19 1 5  (Part.  Med.),  v.  17,  pp.  437-44-  ,  ,  .  ,,    ^ 

Campbell,  A.  W.     Remarks  on  some  neuroses  and  psychoses  m  war.     M.  J. 

Australia,  Sydney,  1916,  i,  pp.  319-323- 
Campbell,  Harry.     War  neuroses.     Practitioner,  Lond.,  1916,  v.  96,  pp.  501-509. 
Camus,  J.     L'evaluation  des  incapacites  fonctionnelles.     Paris  med.,   1916-17, 

(Part.  Med.),  V.  21,  pp.  289-297      _         ,    ^       ^      ,  .       ,t^.     ,  ,      u     • 
Camus,  J.    Le  corps  de  reeducation  physique  du  Grand-palais.    (Depot  de  physio- 

therapie).     Arch,  de  med.  et  pharm.,  mil..  Par.,  1916,  v.  65,  pp.  365-410. 
Camus,  J.     Les  sourds,  leur  placement,  leurs  interets  economiques  et  sociaux. 

Presse  med..  Par.,  1917,  v.  25,  pp.  309. 
Camus,  J.     La  reeducation  des  aveugles  de  guerre.     Presse  med.,  Par.,  1917,  v. 

25,  P-  309- 


91 6  BIBLIOGRAPHY 

Camus,  J.     Placement  et  reeducation  des  grands  infirmes  par  lesions  des  centres 

nerv-eux.     Paris  med.,  191 7.  No.  27,  pp.^  1-5. 
Camus,  J.  et  Nepper.     Recherches  sur  les  reactions  psychomotrices  et  emotives 

des  anciens  trepanes.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  923-924. 
Capelle,  W.     IJber  Prognose  und  Therapie  der  Schadelchiisse.     Miinchen.     Med. 

Wchnschr.,  1917,  64,  Nr.  8. 
Capgras,  Juquelier  et  Bonhomme.     La  confusion  mentale  de  guerre.     J.  de  med. 

de  Bordeaux,  1917,  v.  88,  pp.  164-165.     Rev.  Progres  med.,  Par.,  1917,  v. 

43,  P-  355- 
Cardgill,  L.  V.     Recent  work  on  ophthalmology.     Practitioner,  Lond.,  1916,  v. 

97.  P-  44-  ^  .     ,      . 

Carle,  M.     Vocational  schools  for  war  cripples  m  France.     Amer.  Jour.,  Care 

for  Crip.,  191 7,  v,  165. 
Carle,  M.     Les  ecoles  professionnelles  de  blesses  a  Lyon.     Par.,  1915,  p.  132,  8°. 
Carlill,  Hildred.     The  diagnostic  importance  of  ankle-jerk.     J.  Roy.     Nav.  Med. 

Serv.,  Lond.,  1916,  ii,  pp.  180-190. 
Carlill,  Hildred.     Korsakow's  psychosis  in  association  with  malaria.     Lancet, 

Lond.,  191 7,  i,  V.  192,  pp.  648-650. 
Carlill,  Fildes  and  Baker.     A  report  on  cases  of  syphilis  of  the  central  nervous 

system  observed  in  the  Neurological  Department  of  Royal  Naval  Hospital, 

Haslar,  during  twelve  months.     J.  Roy.  Nav.  Med.  Serv.,  Lond.,  1917,  v.  3, 

PP-  397-427- 
Cas  remarquable  de  protection  cranienne  par  le  casque.     Lyon  med.,  1916,  v. 

125,  pp.  259-261. 
Case  of  Emotional  Mutism.     Brit.  M.  J.,  Lond.,  1916,  i,  p.  769. 
Cases  of  neurasthenia  and  mental  shock.     Mod.  Hosp.,  St.  Louis,  1917,  ix,  368. 
Caspari,  J.     Klinische  Beitrage  zur  Differentialdiagnose  zwischen  Epilepsie  und 

Hysterie  aus  den  Erfahrungen  des  gegenwartigen  Krieges.     Inaug-Dissert., 

Berlin,  1916. 
Cassirer.     Demonstration  eines  Falles  von  Erj'thromelalgie.     Berl.  klin.  Wohn- 

schr.,  1915,  V.  42\  p.  168. 
Cassirer.     Demonstration    von     Verwundeten    mit    erfolgreicher     Nervennaht. 

Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  284-287. 
Cassirer.     Uber    Kombination    funktioneller    und    organischer    Symptome    bei 

Kriegsverletzungen.     Ztschr.  f.  d.  ges.   Neurol.   Psychiat.,   Berl.  u.  Leipz., 

191 6,  V.  30,  p.  229. 
Castex,  Andre.     Surdites  de  guerre.     Bull.  acad.  de  med..  Par.,  1915,  v.  74,  pp. 

547-548. 
Castex,  Andre.     La  reeducation  des  sourds  de  guerre.     (Presentation  de  mili- 

taires  reeduques.)     Bull.  Acad,  de  med..  Par.,  1917,  v.  77,  p.  817. 
Catalepsie  "postmortem."     Caducee,  Par.,  1916,  v.  16,  p.  loi. 
Cathelin,  F.     Classifications  des  troubles  sphincteriens  avec  les  blessures  ou  com- 
motions de  la  region  lombo-sacree.     Paris  med.,  1917,  No.  42,  pp.  319-323. 
Catola,  G.     Neuropatologia  di  guerra;    le   ferite  dei  nervi  periferici.     Riv.  di 

patol.  nerv.,  Firenze,  191 5,  v.  20,  pp.  533-554- 
Catola,  G.     A  proposito  di  alcune  sindromi  nervose  funzionali  di  guerra  con  con- 

siderazioni  in  rapporti  alia  simulazione  nelle  sue  varie  forme.     Riv.  di  patol. 

nerv.,  Firenze,  1916,  v.  21,  pp.  662-675. 
Cestan.     Discussion  de  la  conduite  k  tenir  vis-a-vis  des  blessures  du  crane  —  par 

P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  465-466. 
Cestan;  Descomps,  Paul;  et  Sauvage,  Roger.    Les  troubles  de  I'equilibre  dans  les 

commotions  cranienues.     Paris  med.,  1916  (Part.  Med.),  v.  19,  pp.  518-525. 
Cestan,  R. ;    Descomps,   Paul;  Euziere,   J.     Les  empreintes  digitales  dans  les 

lesions  nerveuses  du  membre  superieur.     Leur  application  au  diagnostic  des 

nevrites  traumatiques.     Presse  med.,  Par.,  1916,  v.  24,  pp.  258-262. 
Cestan,  Descomps,  P.,  et  al.     "  La  marche  sous  courant  galvanique  "  chez  les 

commotionnes  et  les   traumatismes   du   crane.     Bull,   et    mem.    Soc.  med. 

d'  hop.  de  Par.,  1916,  v.  32,  pp.  1730-1747. 
Cestan,  Descomps  P.,  Euziere,  J.  et  Sauvage,  R.     Troubles  de  la  sensibilite 

d'origine  corticale  a  disposition  pseudo-radiculaire  en  epilepsie  Jacksonnienne. 

Rev.  neurol..  Par.,  1917,  v.  24,  pp.  235-242. 
Cestan,  Descomps,  P.,  et  Sauvage,  R.     Sur  une  nouvelle  methode  d'exploration 

du  sens  de  I'wentation  et  de  I'equilibre  chez  les  traumatismes  du  crane.     La 


BIBLIOGRAPHY  917 

sensibilisation  h  I'epreuve  de  Babinski-Weill.     (Rev.  Neurol.,  Par.,  1917,  p. 

368)  Bull,  et  mem.  Soc.  med.  d'  hop.  de  Par.,  1916,  v.  32,  pp.  1381-1403. 
Chalier,  A.  et  Chalier,  J.     Des  phlegmons  provoques  chez  les  soldats.     Rev. 

internat.  de  med.  et  de  chir.,  Par.,  1914-16,  v.  25,  pp.  277-281. 
Chalier,  A.  and  Glenard,  R.     Grandes  blessures  de  guerre.     Rev.  de  Chir.,  191 6, 

li,  210. 
Chamberlin,  J.  W.     Injuries  in  modern  warfare.     Boston  M.  and  S.  J.,  1917,  i, 

p.  113;   also  p.  116. 
Chapin,  F.   Stuart.     The  training  school  of  psychiatric  social  work  at  Smith 

College.     IV.    A  scientific  basis  for  training  social  workers.     Mental  Hy- 
giene, II,  October,  191 8. 
Charon,  R.     Psychopathologie  de  guerre.     Progres  med.,  Par.,  1914,  v.  30,  pp. 

425-428. 
Charon,  R.  et  Halberstadt,  G.     Puerilisme  mental  au  cours  d'une  psychose  post- 

commotionnelle.     Rev.  neurol.,  Par.,  1916,  v.  24,  pp.  316-319. 
Charon,  R.   et  Halberstadt,   G.     Les  troubles  psychiques  des  commotionnes. 

Paris  med.,  1917,  No.  27,  pp.  23-32. 
Charpentier,  R.     tin  cas  de  puerilisme  mental  au  cours  des  operations  de  guerre. 

Rev.  neurol.,  Par.,  191 7,  v.  24,  pp.  296-306. 
Chartier,  M.     Un  cas  de  paralysie  hysterique  persistant  chez  un  sujet  en  danger 

de  mort  par  immersion.     Rev.  neurol..  Par.,  1914-15,  v.  22^,  pp.  1241-1245. 
Chatelin  and  de  Martel.     Blessures  du  crane  et  du  cer^^eau  (Collection  Horizon), 

Paris,  1917. 
Chat3lin,  C.  and  De  Martel,  T.     Wounds  of  the  Skull  and  Brain.     Military 

Medical  Manuals,  Univ.  of  London  Press,  1918. 
CLauvin,  H.  et  Heiser.     A  propos  d'un  cas  de  tetanos  monoplegique.     Rev. 

neurol.,  Par.,  1917,  v.  24,  p.  445. 
Chayanne,  F,     Les  sourds,  leur  placement,  leurs  interets  economiques  et  sociaux. 

Presse  med.,  Par.,  1917,  v.  25,  p.  309. 
CJia/igny,  P.     £tude  medico-legale  sur  les  mutilations  volontaires  par  coup  de 

feu.     Soc.  de  med.  legal  de  France,  Bull.,  Par.,  1915,  v.  12,  pp.  209 — 222. 
Charlgny,  P.     Les  reformes  et  I'aptitude  au  service  militaire.     Soc.  de  med.  leg. 

de  France,  Bull.,  Par.,  1915,  v.  12,  pp.  253-260. 
Chavigny,   P.     Phlegmons   provoques   par  injection  sous-cutanee  d'essence  de 

cerebenthine,  de  petrole  ou  d'essence  de  petrole.     Soc.  de  med.  leg.  de  France, 

Bull.,  Par.,  191 5,  V.  12,  pp.  274-284.  ^ 
Chavlgny,  P.     Psychiatric  et  medecine  legale  aux  armees.     Paris  med.,  1915, 

part,  med.),  v.  17,  pp.  184-189. 
Chavlgny,  P.     A  propos  des  mutilations  volontaires  doit-on  le  dire?     Paris  med., 

1915  (part,  med.),  v.  17,  pp.  384-387. 

Cha</igny,  P.     Psychiatric  des  armees.     Paris  med.,  1915  (part,  med.)  v.  17,  pp. 

415—423. 
Chavig-iy,  P.     fitude  medico-legale  sur  les  mutilations  volontaires  par  coup  de 

fe.i.     Ann.  d'hyg.,  Par.,  1915,  V.  24,  pp.  5y2i. 
Cliavigny,    P.     Psychiatrie    aux    armees.     Therapeutique   et    medecine   legale. 

Paris  med.,  1916  (part,  med.),  v.  19,  pp.  8-13. 
ChavigQjr,  p.     Les  maladies  meconnues.     Anesthesies  et  analgesics  hysteriques. 

Paris  med.,  1916  (part,  med.),  v.  19,  pp.  214-215. 
Chcivigay,  P.     Maladies  provoquees  ou  simulees  en  temps  de  guerre.     Paris  med., 

1916  (part,  med.),  v.  21,  pp.  150-153- 

Chavigay,  P.     Les  explosions  des  champs  de  bataille.     Ann.  d'hyg.,  Par.,  1916, 

V.  25,  pp.  5-25. 
Chavlgny,  P.     La  complicite  dans  la  simulation  et  la  provocation  des  maladies. 

Soc.  de  med.  leg.  de  France,  Bull.,  Par.,  1916,  v.  13,  pp.  74-76; 
Chavigay,  P,     Presentation  d'un  blesse  atteint  de  m.onoplegie  hysterique.     Presse 

med.,  Par.,  1917,  v.  25,  p.  193.  ,  ,     r^       ■  xt 

Chavigay,  P.     Un  fugueur  pendant  la  guerre.     Presse  med.,  Par.,  1917,  No.  31, 

Chavigay,  P.     Un  cas  de  dipsomanie.     Presse  med..  Par.,  1917,  y.  25,  p.  502. 
Chari-ray,  P.     Les  maladies  rares  et  le  diagnostic  de  la  simulation.     Un  cas  de 

"  tic  de  la  marche."     Caducee,  Par.,  1917,  v.  17,  pp.  45-49- 
Chavigay  et  Laurens.     Un  fugueur  pendant  la  guerre.     Rev.  neurol.,  Par.,  1917, 

V.  24,  p.  486. 


91 8  BIBLIOGRAPHY 

Chavigny  et  Spillman,  L.     Un  cas  de  hystero-traumatisme  revu  15  ans  apres  les 

accidents  initiaux.     Paris  med.,  1916  (part,  med.)  v.  19,  pp.  525-527. 
Chevallier.     Installation   et   resultats   du   service   de  reeducation   physique  et 

massage  au  cantonnement  de  Villetaneuse  occupe  par  le  N*  regiment  de 

Zouaves.     Arch,  de  med.  et  pharm.  mil.,  Par.,  1916,  v.  65,  pp.  411-433. 
Chevallier,  Paul.     Traitement  pratique  de  la  blennorragie  chez  I'homme.     Presse 

med..  Par.,  1917,  v.  25,  pp.  573-574- 
Chevalier-Lavaure.     A  propos  de  la  reforme  des  militaires  alienes.     Montpel. 

med.,  1916,  n.s.,  v.  39,  pp.  418-427. 
Chevassu,   M.     Les   traumatismes   cranio-cerebraux   dans   la  zone  de  I'avant. 

Montpel.  med.,  1916,  v.  39,  p.  29. 
Cheyrou.     Reactions  immediates  obser\-ees  a  la  suite  d'eclatements  a  proximite 

de  projectiles  de  guerre.     Caducee.  Par.,  1917,  xvii,  31-33. 
Chiari,  H.     Zur  Pathogenese  der  Meningitis  bei  Schussverletzungen  des  Gehirns. 

Miinch.  med.  VVchnschr.,  1915,  v.  62',  pp.  596-598. 
Chiray.     Centre  neurologique  de  la  10^  region  (Rennes).     Rev.  neurol..  Par., 

1916,  v.  23,  pp.  672-686. 
Chiray.     Discussion  de  la  condulte  a  tenir  vis-a-vis  des  blessures  du  crine  —  par 

P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  p.  472. 
Chiray,  J.,  Bourguignon,  G.  et  Dagnan-Bouvert.     Interpretation  des  discordances 

entre  les  reactions  electriques  et  les  signes  cliniques,  dans  les  lesions  nerveuses 

peripheriques.     Paris  med.,  1916  (part,  med.)  v.  21,  pp.  220-224. 
Cimbal.     Psychosen  und  Psychoneurosen  im  IX.  Armeekorps  seit  der  Mobil- 

machung.     Berl.  klin.  Wchnschr.,  191 5,  v.  52,  p.  304. 
Cimbal.     Die  seelischen  und  nervosen  Erkrankungen,  seit  der   Mobilmachung. 

Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  411-415. 
Clarke,  C.  K.     Psychiatric  treatment.     Mil.  Hosp.  Com.  Canada,  Spec.  Bull., 

Ottawa,  1916,  p.  loi. 
Clark,  D.  A.    Treatment  by  physical  methods  of  mental  disabilities  induced  by  the 

war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10  (sect.  Balneol.),  pp.  12-18. 
Clark,  E.     Eyesight  and  the  war.     Med.  Press  and  Circ,  Lond.,  1916,  ii,  pp. 

72-74.     Also:    Nature,  Lond.,  1916,  v.  96,  pp.  552-555. 
Clark,  E.     Clinical  lecture  on  eyesight  and  the  war.     Aled.  Press  and  Circ,  Lond., 

1916,  V.  102,  p.  72. 

Clarke,  J.  Mitchel.  Some  neuroses  of  the  war.  Bristol.  M.  Chir.  J.,  1916,  v.  34, 
p.  130.     Rev.  J.  Nerv.  and  Ment.  Dis.,  N.  Y.,  1917,  i,  p.  119. 

Claude,  Henri.  Les  etats  nevropathiques  (Rev.  neurol.,  Par.,  1914-15),  v.  22^, 
p.  1 162. 

Claude,  H.  L'organisation  et  le  fonctionnement  des  centres  neurologiques 
regionaux.     Paris  med.,  1915  (part,  med.),  v.  17,  pp.  61-65. 

Claude,  H.  Discussion  de  accidents  nerveux  par  la  deflagration  des  explosifs. 
Rev.  neurol..  Par.,  1916,  v.  23,  pp.  587-590. 

Claude,  H.  Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  cr&ne  — 
par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  460-462. 

Claude,  H.     Discussion  de  Vincent.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  587. 

Claude,  H.  De  revolution  des  incapacites  dans  les  attitudes  vicieuses  sans  rap- 
port avec  des  lesions  organiques  appreciables.     Paris  Medical,  octobre  1916. 

Claude,  H.  War  neurology;  traumatic  lesions  of  nerves  by  projectiles.  Med. 
Press,  and  Circ,  Lond.,  1916,  v.  102,  p.  72,  and  p.  469. 

Claude,  H.  L'evaluation  des  incapacites  dans  les  attitudes  vicieuses  sans  rapport 
avec  des  lesions  organiques  appreciables.  Paris  med.,  1916-17,  v.  21,  pp. 
300-305. 

Claude,  H.  L'anesthesie  regionale  associee  aux  methodes  psychophysiothera- 
piques  dans  le  traitement  des  attitudes  vicieuses  et  des  tremblements  des 
membres  inferieurs  d'ordre  fonctionnel.     Bull.  et.  Soc.  med.  d'  hop  de  Par., 

1917.  V.  33,  PP-  424-430.  . 
Claude  et  Chauvet.     Semiologie  reelle  des  sections  totales  des  nerfs  mixtes  peri- 
pheriques.    Paris,  1901. 

Claude,  H.,  Dide,  M.,  et  Lejonne,  P.     Psychoses  hystero-emotives  de  la  guerre. 

Paris  med.,  1916,  v.  21,  pp.  181-185. 
Claude,  Henri,  et  Lhermitte,  J.     Etude  clinique  et  anatomo-pathologique  de  la 

commotion  medullaire  directe  par  projectiles  de  guerre.     Ann.  de  med..  Par., 

1914-15,  v.  2,  pp.  479-506. 


BIBLIOGRAPHY  919 

Claude,  Henri,  et  Lhennitte,  J.     Le  tetanos  frusta  a  evolution  lente  et  incubation 

prolongee.     Etude  des  reactions  electriques.     Presse  med.,  1915,  14  oct.,  p. 

406. 
Claude,  Henri,  et  Lhennitte,  J.     Les  reflexes  tendineux  et  cutanes,  les  mouve- 

ments  de  defense  at  d'automatisme  dans  la  section  totale  de  la  moelle  d'apres 

une  observation  anatomo-clinique.     Ann.   de  med.,   Par.,   1916,   v.   3,  pp. 

407-430. 
Claude,   Henri,    et   Lhennitte,    J.     Les   paraplegics   cerebello-spasmodiques   et 

ataxo-cerebello-spasmodiques  consecutives  aux  lesions  bilaterales  des  lobules 

paracentraux  par  projectiles  de  guerre.     Soc.  med.  d'hop.  de   Par.,  1916, 

26  mai. 
Claude,  Henri,  et  Lhennitte,  J.     La  glycosurie  dans  les  lesions  traumatiques  du 

cerveau.     Soc.  med.  d.  hop.  de  Par.,  1916,  26  mai. 
Claude,  Henri,  et  Lhennitte,  J.     Les  contractures  du  tetanos  tardif  a  evolution 

prolongee  et  leur  diagnostic  avec  les  contractures  organiques  ou  "  fonction- 

nelles."     Progres  med.,  Par.,  1916,  pp.  185-187. 
Claude,  Henri,   et  Lhermitte,   J.     Troubles  medullaires  dans  les  commotions 

directes  mais  a  distance  de  la  colonne  vertebrale.     Paris  med.,  191 7,  No.  27, 

PP-  ^^-^4-  .   .  ,     ,  .        , 

Claude,  H.,  et  Lhennitte,  J.     Formes  clmiques  de  la  commotion  de  la  moelle 

cervicale  par  projectiles  de  guerre.     Rev.  deemed.  Par.,  19 16,  35,  535-554. 
Claude,  Henri,  et  Lhennitte,  J.     Le  syndrome  infundibulaire  dans  un  cas  de 

tumeur  du  troisieme  ventricule.     Presse  med..  Par.,  1917,  v.  25,  pp.  417-418. 
Claude,  H.,  et  Lhennitte,   J.      Les  modifications  dynamogeniques  des  centres 

nerveux  inferieurs  dans  les  paralysies  ou  dans  les  contractures  fonctionnels. 

Presse  med.,  1918,  No.  i.  _ 

Claude,  Henri,  et  Porak,  R.     De  la  decalcification  osseuse  dans  les  paralysies  des 

membres  organiques  ou  nevropathiques.    Paris  med.,  1915,  v.  17  (part,  med.), 

pp.  321-328. 
Claude,  Henri,  et  Porak,  R.     Les  troubles  de  la  motihte  dans  les  psychonevroses 

du  type  hysterique.     Progres  med.,  Par.,  1914-15,  v.  23,  p.  486  and  p.  512. 

Rev.  Paris  med.,  1915,  v.  17  (part,  med.),  p.  540. 
Claude,  Henri,  et  Lhermitte,  J.  et  Loyes,  Mile.  M.     Etude  histologique  d'un  cas 

de  commotion  meduUaire  par  eclatement  d'obus.     Bull,  et  mem.  Soc.  med. 

d'hop.  de  Par.,  1915,  v.  39,  pp.  680-687. 
Claude,  Henri,  Lhennitte,  J.,  et  Vigouroux,  A.     Delire  mystique  chez  un  blesse 

de  I'encephale.     Ann.  med.-psychol..  Par.,  1917,  v.  73,  pp.  560-568. 
Claude,  Henri,  Loyes,  Mile.  M.,  et  Lhennitte,  J.     Etude  clinique  et  anatomique 

de  la  commotion  meduUaire  par  eclatement  d'obus.     Rev.  Paris  Med.,  1915, 
V.  17  (part,  med.),  p.  370.      , 
Cleude,  Vigouroux,  et  Dumas.     Etude  anatomique  de  cent  cas  de  lesions  trau- 
matiques des  nerfs  des  membres.     Presse  Med.,  March  4,  I9I5._ 
Clerici,  A.     Disturbi  psichici  nei  soldati  combattenti.     Riv.  di.  psicol.  applic, 

Bologna,  1915,  v.  11,  pp.  112-117. 
Clinical  aspects  of  hemilesions  of  the  cord.      N.  Y.  Med.  Jour.,  1917,  cvi,  1189. 
Clunet,  Jean.     Les  effets  immediats  de  I'emotion  sur  le  systeme  nerveux,  en 

dehors  de  toute  commotion.     Rev.  neurol..  Par.,  1917,  v.  24,  pp.  48-51. 
Cluzet.     Paralysie  du  plexus  brachial  aves  troubles  trophiques  de  la  rnain,  sans 

blessure    ni    contusion   apparente,    provoquee   par   I'explosion   d'un   obus. 

Lyon  med.,  1916,  v.  125,  p.  20. 
Cohn,    Toby.     (Discussing  Lewandowsky)  —  "  Kriegsverletzungen  des  Nerven- 

systems."     Deutsche  med.  Wchnschr.,  Bed.  u.  Leipz.,  1915,  v.  41,  p.  89  and 

p.  149. 
Cohn,  Toby.     Zur  Frage  der  psychogenen  Komponente  bei  Motilitatdefekten 

infolge  von  Schussverletzungen.     Neurol.  Zbl.,  Leipz.,  1916,  v.  35,  No.  6. 
Cohn,  Toby,  Kron,  H.,  and  Hansemann,  etc.     Ueber  Kriegsverletzungen  des 

Nervensystems.     Discussion  before   Referat  of  Lewandowsky.     Berl.  klin. 

Wchnschr.,  1915,  v.  521,  pp.  88-91.  .     •  .,  r-  .     • 

Colella,  R.     Arteriosclerosi  e  neurosi  posttraumatiche.     Gazz.  med.  sicil.  t^atama, 

1916,  xix,  121-128.  ,.,.,.. 

Colin,  H.     De  I'envoi  en  conge  de  convalescence  des  alienes  militaires  guens  et 

fortunes  en  cas  de  refus  du  certificat  d'hebergement.     Soc.  de  med.  leg.  de 

France,  Bull.,  Par.,  1916,  v.  13,  pp.  136-146. 


920  BIBLIOGRAPHY 

Colin,  H.  et  Lautier,  J.     De  la  valeur  emotionnelle  des  maladies  veneriennes  dans 

I'etiologie  et  revolution  des  psychoses.     Ann.  med.-psychol.,  Par.,  191 7,  v. 

73.  PP-  357-373- 
Colin,  H.,  Lautier,  et  Magnac.     Les  imbeciles  a  1  'armee.     Ann.  med.-psychol., 

Par.,  1916-17,  V.  7,  pp.  540-546. 
Collie,   Sir   John.     Fraudulent   and   neurasthenic   cases.     Tr.    Med.-Leg.    Soc., 

Lond.,  1914-15,  V.  12,  pp.  25-67. 
Collie,   Sir   John.     Fraudulent  and   neurasthenic  cases.     J.    Roy.   Army  Med. 

Corps,  Lond.,  191.S,  v.  24,  pp.  653-682;  also  Practitioner,  Lond.,  1915,  v.  44, 

PP-  653-682. 
Collie,  Sir  John.     Fraud  and  skin  eruptions.     Lancet,  Lond.,  1916,  ii,  pp.  1007- 

lOIO. 

Collie,  Sir  John.     Neurasthenia;    what  it  costs  the  State.     J.  Roy.  Army  Med. 

Corps,  Lond.,  1916,  v.  26,  pp.  525-544. 
Collie,  Sir  John.     Tests  for  simulated  defective  vision  or  for  blindness  of  one  eye. 

J.  Roy.  Army  Med.  Corps.,  Lond.,  1916,  v.  26,  pp.  800-812. 
Collie,  Sir  John.     Jaundice  and  malingering.     Birmingh.  M.  Rev.,  1916,  v.  80, 

PP-  93-94-  .... 

Collie,  Sir  John.     Malmgermg:   exammation  of  the  upper  extremities.     J.  Roy. 

Army  Med.  Corps,  Lond.,  1916,  v.  27,  pp.  85-91. 
Collie,  Sir  John.     Malingering  and  feigned  sickness.     2nd.  ed.,  191 7. 
Collie,  Sir  John.     La  simulazione  dei   dolori  di  schiena.      Gazz.   med.  lomb., 

Milano,  1917,  xxiv,  129-132. 
Collie,  Sir  John.     Treatment  by  physical  methods  of  mental  disabilities  induced 

by  the  war.      Proc.  Roy.  Soc.  Med.,  Lond.,  191 7-18  (sect.  Balneol.),  v.  10, 

pp.  21-24. 
Collie,  Sir  John.     The  management  of  neurasthenia  and  allied  disorders  contrac- 
ted in  the  Army.     With  report  of  remarks  made  by  Lt.  Col.  Aldren  Timier. 

"  Recalled  to  Life,"  191 7,  Sept.,  No.  2,  pp.  234-250. 
Collier,  James.     Shell  shock  without  visible  signs  of  injury.     Proc.  Roy.  Soc. 

Med.,  1915-16,  V.  9  (sect.  Psychiat.),  pp.  34-35. 
Collier,    James,     Gunshot   wounds  and   injuries  of  the  spinal  cord.     Lancet, 

Lond.,  1916,  i,  pp.  711-716.     Also  Tr.  M.  Soc,  Lond.,  1915-16,  v.  39,  pp. 

227-256. 
Collins,  J.  and  Craig,  C.  B.     Injuries  to  spinal  cord  produced  by  modern  warfare. 

J.  Nerv.  and  Ment.  Dis.,  N.  Y.,  1916,  v.  44,  pp.  527-528. 
Colmers,    F.     Ueber    Schadelschiisse.      Deutsche    med.    Wchnschr.,    1917,   43, 

741. 
Cololian.     La  mecanotherapie  de  guerre  avec  les  appareils  de  fortune.     Arch,  de 

med.  et  pharm.  mil..  Par.,  1914-15,  v.  64,  pp.  155-176;   also  pp.  658-695. 
Commotion  des  centres  nerveux  par  explosion.      Lyon  med.,  1916,  v.  125,    pp. 

181-182. 
Commotionnes  vrais.     Caducee,  Par.,  191 6,  v.  16,  p.  172. 
Condorelli-FrancavigUa,    M.     Congiuntivite   catarrhale    acuta    in    un    militare, 

provocata  mediante  I'uso  di  semi  di  ricino.     Policlin.,  Roma,  191 7,  xxiv,  sez. 

prat.,  735-739- 
Conference  interall.ee   pour  1' etude   de  la  reeducation  professionelle   et  des 

questions  qui  interessent  les  invalides  de  la  guerre.    .  Grand-Palais,  Paris, 

May  8-12,  1917.     Proc.  Roy.  Soc.  Med.,  Lond.,   1917-1918  (Sect.  Balneul. 

and  Climatol.),  v.  10,  pp.  81-95. 
Cone,  S.  M.     Pathological  findings  in  nerves  in  following  war  injuries;    pre- 
liminary report.     Brit.  Med.  Jour.,  1917,  ii,  615. 
Cone,  Sydney  M.     Some  of  the  results  of  work  on  the  pathology  of  peripheral 

nerve  injuries.     Amer.  Jour.  Orthop.  Surg.,  1918,  xvi,  319. 
Cone,  Sydney  M.     Surgical  pathology  of  the  peripheral  nerves.     Brit.  Jour,  of 

Surg.,  1918,  vi,  524. 
Congres  interallie  de  reeducation  des  mutiles.     Presse  med.  Par.,  1917,  v.  25, 

pp.  301-303. 
Consiglio,   P.     Studii  di  psichiatria  militaire.     Riv.  sper.  di  freniat.,   Reggio- 

Emilia,  1912,  v.  38,  p.  370;    1913.  v.  39,  p.  792;    1914,  v.  40,  p.  881 ;    1915.  v. 

41.  P-  35-  .... 

Consiglio,  P.    Delle  psicosi  e  delle  nevrosi  e  specialmentedella  criminalita  m  guerra. 
Ann.  di  med.,  nav.,  Roma,  1915,  ii,  pp.  408-417. 


BIBLIOGRAPHY 


921 


Consiglio,  P.     Psicosi,  nevrosi  e  criminalita  nell'  ambiente  militare  in  tempo  di 

pace.     Ann.  di  med.,  nav.,  Roma,  1915,  ii,  pp.  418-422. 
Consiglio,  P.     Nevrosi  e  psicosi  in  guerra.     (Nota  2)  Gior.  di  med.  mil.,  Roma 

1915,  V.  63,  pp.  665-703. 
Consiglio,  P.     Studien  uber  Militar-psychiatrie  und  Kriminologie.     Ztschr.  f.  d. 

Ges.  Neurol.  _u.  Psychiat.,  Berl.  u.  Leipz.,  1915,  v.  128,  pp.  384-444. 
Consiglio,  P.     Psicosi  nevrosi  e  criminalita  nei  militari  in  guerra.     Arch,   di 

antrop.  crim.,  etc.,  Torino,  1916,  v.  8,  pp.  258-268. 
Consiglio,  P.     L'Anomalie  de  caratterre  dei  militari  in  guerra.     Riv.  sper.  di 

freniat.,  Reggio-Emilia,  1916,  v.  42,  pp.  131-172. 
Consiglio,  P.     Disturbi  nervosi  e  mentale  nei  militari  in  guerre.     Gior.  di  med. 

mil.,  1917,  v.  65,  pp.  607-616. 
Cooper,  George.     Contractures  and  allied  disorders:  their  cause  and  treatment. 

Brit.  M.  J.,  Lond.,  1917,  i,  pp.  109-114. 
Cooper,  P.  R.     (Discussion  of  Milligan's  paper.)    Brit.  M.  J.,  Lond.,  1916,  ii,  p.  73; 

also  p.  201. 
Cooper,  J.  "W.  A.     Use  of  alcohol  on  the  battlefield  and  elsewhere.     Lancet,  Lon., 
iti     1914,  ii,  1168. 

Cooper,  P.  R.     Treatment  of  "  shell  shock,"  Brit.  M.  J.,  Lond.,  1916,  ii,  201. 
Cordier,  Charles  Albert.     Les  etats  psychastheniques  frustes  et  la  guerre.    These 

de  Lyon,  1916.     Rev.  neurol..  Par.,  1917,  v.  22,  p.  471. 
Core,  Donald  E.     The  "  Instinct-distortion,"  or  "  war  neurosis."     Bos.  M.  and 

S.  J.,  1918,  clxxix,  448. 
Core,    Donald    E.     "  Instinct-distortion,"    or    "  war- neurosis."     Lancet,    Lon., 

1918,  ii,  168. 
Comet.     L'auto-mutilation.     Rev.  gen.  de  clin.  et  de  therap..  Par.,  1915,  v.  29, 

pp.  649-653;   and  pp.  683-686. 
CosteUo,  C.  A.     Principal  defects  found  in  persons  examined  for  service  in  the 

United  States  Navy.     Amer.  Jour.  Pub.  Health,  191 7,  vii,  489. 
Cottet,  J.     Troubles  objectifs  de  la  sensibilite  cutanee  dans  les  gelures  des  pieds: 

I'acrotrophodynie  paresthesique  des  tranchees.     Paris  med.,   1917,  No.  11, 

pp.  222-27. 
Cottet,  J.     Syndrome  d'aero-paresthesie  a  frigore  et  gelures  des  pieds.     Presse 

med.,  Par.,  1917,  v.  25,  pp.  517-518. 
Courtois,  Suffit  M.  et  Giroux,  R.      Les  formes  anormales  du  tetanos.      1916, 

Paris,  Masson  et  Cie. 
Craig,  C.  B.     Injuries  to  the  peripheral  nerves  produced  by  modern  warfare. 

Am.  Jour.  Med.  Jour.,  1916,  clii,  368.  -^ 

Craig,  Maurice.     Psychological  medicine.     1917,  3rd  ed.,  Blakiston,  pp.  300-311. 
Crile,  G.  W.     The  Kinetic  Drive.     W.  B.  Saunders,  1916. 
Crile,  G.  W.     A  mechanistic  view  of  war  and  peace.     Macmillan,  191 6. 
Crile,  G.  "W.     Man:   An  adaptive  mechanism.     Macmillan,  191 6. 
Crile,  G.  W.     Notes  on  Base  Hospital  No.  4,  U.  S.  A.,  on  Active  Service.     J. 

Am.  M.  Asso.,  Chicago,  1917,  v.  Ixix,  p.  206. 
Crile,    G.    W.     The   Fallacy   of   the   German   State    Philosophy.     Doubleday, 

Page,  1918. 
Crinon,  J.     Les  eclopes  psychiques.     (Med.  legale.)     Caducee,  Par.,  1916,  v.  16, 

pp.  115-116. 
Crinon,  J.     Les  centres  psychiatriques  de  1' avant.     Progresmed.,Par.,  1917,  v.  43, 

pp.  364-365. 
Cristiani,  A.      Note  practiche  (psichiatriche  militari).       Riv.  ital.  di  neuropat. 

(etc.),  Catania,  1917.     x  265-272. 
Crouzon,  O.     Cecite  temporaire  provoquee  par  I'eclatement  d'obus  k  proximite. 

Bull,  et  mem.  soc.  d'hop.  de  Par.,  1915,  v.  39. 
Crouzon,  O.     Les  pseudo-maux  de  Pott  au  conseil  de  revision.     La  spondylite 

traumatique.      Bull,   et   mem.   soc.   med.   de   Par.,    1915,   v.   39,   pp.    iil- 

113-  ,    ,  , 

Crouzon,'0.     Hemorrhagies  naso-pharyngiennes  profuse  et  repetees  apres  conimo- 

tion  par  eclatement  d'obus  chez  un  sujet  atteint  d'hypertension  arterielle. 

Bull,  et  mem.  Soc.  med.  d'hop.  de  Par.,  19x6,  3.S.  xl,  1376-1378. 
Crouzon,  O.     De  la  valeur  de  I'hypotension  arterielle  comme  signe  objectif  de  la 

psychasthenie.       Bull,  et   mem.  soc.  med.  d'hop.  de  Par.,  1915.  ^'-  39.  PP- 

234-237- 


922 


BIBLIOGRAPHY 


Cruchet,  R.  Calmettes  et  Bertrand,  £pilepsie  Jacksonienne  grave.  Trepanation 
et  application  de  sac  herniaire.  Cessation  des  crises.  Disparition  des 
troubles  subjectifs.     Rev.  neurol.,  Par.,  1917,  v.  24,  pp.  510-51 1. 

Cruchet,  R.  Calmettes  et  Bertrand.  Fracture  du  crane  meconnue.  Commo- 
tion cerebrale.  Crises  d'hystero-epilepsie  avec  etat  obsenant.  Trepana- 
tion tardive.     Guerison.     Rev.  neurol.,  Par.,  1917,  v.  24,  pp.  511-513. 

Culpin,  M.  Practical  hints  on  functional  disorders.  Brit.  M.  J.,  Lond.,  ii,  pp. 
548-549. 

Cumberbatch,  E.  P.  A  criticism  on  the  reaction  testing  of  muscles  and  the 
interpretation  of  the  results  with  reference  to  electrical  examination  of 
nerve  injury  in  war.  Proc.  Roy.  Soc.  Med.,  Lond.,  1915-16,  v.  9  (Electro.- 
therap.  sect.),  pp.  23-38. 

Curschmann.  Bemerkungen  zur  Behandlung  hysterischer  Stimmstorungen. 
Miinchen  med.  Wchnschr.,  1916,  v.  63,  pp.  1644-1645. 

Cutler,  E.  C.     Neurological  surgery  in  a  war  hospital.     Boston  M.  and  S.  J., 

1916,  V.  174,  pp.  305-309- 

Cygielstrejch,  Adam.     La  psychologie  de  la  panique  pendant  le  guerre.     Ann. 

med.-psychol..  Par.,  1916-17,  v.  7,  pp.  172-192. 
D'Abundo,   G.     Alterazioni  nel  sistema  nervoso  centrale  consecutive  a  parti- 

colari  commozioni  traumatiche.     Riv.  ital.  di  neuropat.,  Catania,  1916,  v.  9, 

pp.  145-171. 
D'Abundo,  G.     Considerazioni  cliniche  sui  traumi  di  guerra  a  capo.     Riv.  ital. 

di  neuropat.  psichiatr.,  ed  elettroter.,  1917,10,  357-76. 
D'Abundo,  G.     Reparto  neuropatologico  militarizzato  della  clinica  delle  malattie 

nervose  e  mentale  della  R.  Universita  di  Catania.     Riv.  ital.  di  neuropat., 

Catania,  1917,  v.  10,  pp.  22-24. 
Dacco,  E.     Autolesioni  cutanea  nei  militari.     Gior.  ital.  d.  mal.  ven.,  Milano, 

191 7,  Hi,  340,  370. 

Dal  CoUo,  M.  E.     Contributo  casuistico  alle  dermatosi  simulate  di  guerra.     Qua- 

derni  di  med.  leg.,  Milano,  1917.  i.  24-29. 
Damaye,  H.     Organisation  et  fonctionnement  d'un  service  de  neuropsychiatrie, 

d'armee.     Presse  med..  Par.,  1916,  v.  24,  p.  24. 
Damaye,  H.     fitude  sur  les  affections  mentales  et  neuropathiques  occasionnees 

par  les  commotions  de  la  guerre.     Progres  med..  Par.,  1917,  3.  s.,  xxxii,  441- 

443. 
Damaye,  H.     Organisation  des  centres  psychiatriques.     Caducee,   Par.,   191 7, 

V.  126,  p.  147. 
Damaye,  H.     Considerations  cliniques  sur  les  commotions  de  la  guerre.     Pro- 
gres med..  Par.,  1917,  3.  s.,  xxxii,  332-334. 
Damaye,  H.      Apergu  general   sur   les    fonctions   d'un   service   de    psychiatrie 

d'armee.     Progres  med..  Par.,  191 7,  v.  43,  pp.  362-364. 
Dames  de  la  Croix-Rouge  et  la  simulation.     Caducee,  Par.,  19 16,  v.  16,  p.  94. 
Darkshevich,  L.  O.     (Nomenclature  of  disturbances  in  the  region  of  the  nervous 

system,  following  traumatism.)     Russk.  Vrach.,   Petrogr.,    1916,  v.   15,   p. 

97- 

Daude.  Contribution  a  I'etude  de  la  psychopathologie  de  guerre.  Fonctionne- 
ment d'un  centre  psychiatrique  de  I'avant.     These  de  Bordeaux,  1916. 

Daussant.  L'assistance  aux  invalides  et  mutiles  de  la  guerre  (appareillage, 
reeducation    professionelle,    placement).     Arch,    de    med.    et    pharm.    mil.. 

Par.,  1916,  V.  65,  pp.  733-759- 
Davidenkoff,  S.  N.     (Acute  psychoses  in  time  of  war.)     Psikhiat.     Gaz.,  Petrogr., 

1915,  V.  2,  pp.  321-325-  .  .         ,  .  .  .        . 

Davidenkoff,    S.    N.      (Dysarthria    and    mutism    followmg   wind    contusions.) 

Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  190-194. 
Davidenkoff,    S.    N.     Acute    traumatic    psychoses;     retroanterograde    amnesia 

after  traumatism  of  the  skull.     Ibid.,  341-347.  _ 
Davidenkoff,   S.   N.     (Case  of  hysterical  psychosis  developed  during  battle.) 

Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  211-213. 
Davidenkoff,  S.  N.     (Nature  of  speech  disturbances  in  the  contused.)     Sovrem. 

Psikhiat.,  Mosk.,  1916,  v.  10,  pp.  292-373. 
Davidson,  J.  M.  and  Lockhart-Mummery,  P.     Fragment  of  shell  embedded  in 

the  internal  popliteal  nerve:    illustrating  the  value  of  accurate  localization. 

Lancet,  Lon.,  1917,  i,  719. 


BIBLIOGRAPHY  923 

Dawson,  G.  H.     A  case  of  shell  concussion:    treatment  by  general  anaesthesia. 

Lancet,  Lond.,  1916,  i,  p.  463. 
De   Boer,    J.     Desertie   en   vagabondage.     Mill.-geneesk.    Tijdschr.,    Haarlem, 

1917,  V.  21,  pp.  149-167. 
De  Brun,  H.     L'amnesie  paludienne,  Presse  med.,  Par.,  1917,  v.  25,  pp.  625-627. 
Dedor,  V.  P.     (Skull-brain  wounds,  according  to  the  data  of  the  evacuational 

hospital  No.  88.)     Russk.  Vrach.,  Petrogr.,  1917,  v.  17,  pp.  429-431,  and 

pp.  450-454- 
DeFleury,   Maxirice.     Un  moyen  de  delassement  pour  les  troupes  en  marche. 

Bull,  de  Acad,  de  med.,  Par.,  1914,  v.  72,  pp.  442-443. 
Dejerine,  J.     Deux  cas  de  paraplegic  fonctionnelle  d'origine  emotive  observee 

chez  des  militaires.     Rev.  neurol.,  Paris,  191 5. 
Dejerine,  J.      Sur  I'abolition  de  reflexe  cutane  plantaire  dans  certains  cas    de 

paralysies  fonctionnelles,  accompagnees  d'anesthesie  (hystero-traumatisme). 

Rev.  neurol.,  Paris,  1914-15,  v.  22\  pp.  521-529. 
Dejerine,   J.     Deux  cas  de  paralysie  fonctionnelle  d'origine  emotive  observes 

chez  les  militaires.     Rev.  neurol.,  Par.,  1914-15,  v.  22^,  pp.  421-424. 
Dejerine  et  Gascuel.     Tachycardie  d'origine  emotive  permanente.     Rev.  neurol.. 

Par.,  1914-15,  V.  22-,  pp.  211-214. 
Dejerine,  J.  et  Gauckler,  E.     Le  traitement  par  I'isolement  et  la  psychothe- 

rapie  des  militaires  atteints  de  troubles  fonctionnels  du  systeme  nerveux. 

Presse  med.,  Par.,  1915,  v.  23,  pp.  521-522. 
Dejerine,  Marie,  Babinski,  Claude,  Leri,  Sollier,  Sicard.,    Travaux  des  centres 

neurologiques.     Rev.  neurol..  Par.,  1915,  p.  1136. 
Dejerine  et  Mouzon.     Deux  cas  de  syndrome  sensitif  cortical.     Rev.  neurol.,  Par., 

1914-15,  V.  222,  p.  388. 
Dejerine  et  Mouzon.     Les  lesions  des  gros  troncs  nerveux  par  projectiles  de 

guerre.     Les  differents  syndromes  cliniques  et  les  indications  operatoires, 

Presse  med.,  May  10,  July  8,  Aug.  30,  1915. 
Dejerine  et  Mouzon.     Un  nouveau  type  de  syndrome  sensitif  cortical  dans  un 

cas  de  monoplegie  corticale  dissociee.     Rev.  neurol..  Par.,  1914-15,  v.  22^, 

pp.  1265-1273. 
Dejerine  et  Mouzon.     Le  diagnostic  de  ['interruption  complete  des  gros  troncs 

nerveux  de  membres.     Presse  med..  Par.,  1916,  v.  24,  pp.  97-101. 
Dejerine,  M.  and  Mme.  and  Mouzon.     Troubles   trophiques   articulaires  ana- 
logues a  ceux  du  rhumatisme  subaigu  et  semblant  consecutif  a  un  tiraille- 

ment  des  racines  des  plexus  brachiaux  chez  un  soldat  atteint  de  paraplegie 

traumatique.     Rev.  neurol.,  Paris,  1915. 
Dejerine  et  Schwartz.     Deformations  articulaires  analogues  a  celles  du  rhuma- 
tisme chronique,  avec  troubles  trophiques,  cutanees  et  hyperidrose  relevant 

d'une  lesion  irritative  du  nerf  median.     Rev.  neurol.,  Paris,  191 5. 
De  la   Motte.     Demonstration  zweier  forensischer  Falle.     Neurol.   Centralbl., 

Leipz.,  1915,  V.  34,,PP-  599-591- 
De  Lapersonne.     La  reeducation  des  aveugles  de  guerre.     Presse  med.,   Par., 

1917,  V.  25,  p.  309. 
Del    Greco,    Francesco.     Gli  ansioso  emotivi.      Riv.    ital.    di    neuropat.      (Psi- 

chiat.  ed  elettro.)     Catania,  1917,  v.  10,  pp.  169-183. 
Delherm,  L.     Note  sur  les  contractures  et  les  paralysies  traumatiques  d'ordre 

reflexe.     J.  de  radiol.  et  d'electrol.,  Par.,  1916,  v.  2,  pp.  292-300. 
Delherm,  L.     Le  traitement   des  phenomenes   hysteriques   par  la  reeducation 

intensive  d'apres  CI.  Vincent.     J.  de  radiol.  et  d'electrol..  Par.,  1917,  v.  2, 

PP-  531-532- 
Delhenn  and  Py.     De  ['importance  de  bien  differencier  les  manifestations    organ- 

iques  et  les  manifestations  psychiques  chez  les  blesses  de  guerre.     J.  de 

radiol.  d'electrol..  Par.,  1914-15,  i,  625-628. 
Delinquent  children  and  the  war.     Brit.  M.  J.,  Lond.,  1917,  i,  p.  231. 
DeUre  raisonnant  d'invention.    Ann.  med.-psychol.,  Par.,  1917,  v.  73,  pp.  589-594. 
De  Lisi,  L.     Ricerche  sperimentali  sulle  alterazioni  nervose  centrali  degli  an 

nuali  sottoposti  a  commozione  cerebrale.     Riv.  sper.  di  freniat.,   Reggio- 

Emilia,  1915,  v.,  41,  pp.  249-312. 
Delorme,  Edmond.     Sur  la  frequence  des  troubles  des  organes  des  sens,  et  en 

particulier  de  la  vision,  dans  les  blessures  de  la  tete  par  les  projectiles.     Bull. 

Acad,  de  med.,  Par.,  1915,  v.  73,  P-  397- 


924  BIBLIOGRAPHY 

DeMartel,  T.     Blessures  du  crane.     Collection  Horizon,  Masson  et  Cie,  Paris, 

1917- 
De  Massary,  E.,  et  Du  Soulch,  P.     Syndrome  choreiforme  hysterique  et  paralysie 

generate  incipiens.     Rev.  neurol.,  Par.,  191 7,  v.  24,  pp.  219-221. 
De  Massary,  E.,  et  Tockmann.     Un  cas  de  paludisme  avec  reaction  meningee 

violente  simulant  la  meningite  cerebrospinale.     Bull,  et   mem.    Soc.   med. 

d'hop.  de  Paris,  1917,  3  ser.  41,  1 195-9- 
Deny,  G.     La  neuropsychopathologie  frangaise  pendant  une  annee  de  guerre 

(aout  1914-aout  1915).     Encephale,  Par.,  1914-15,  ii,  pp.  153-174. 
Deny,    G.      Sur   trois   cas   d'hystero-traumatisme    (monoplegie   brachiale,    con- 
tracture dorso-lumbaire,  meteorisme).     Rev.  neurol..  Par.,  1914-15,  v.  221, 

PP-  559-560.  .... 

De  Paeuw,  Leon.     The  Vocational  Reeducation  of  Maimed  Soldiers.     Princeton 

Univ.  Press,  191 8. 
De  Parrel,  G.     Surdite  de  guerre  et  methode  orale.     Rev.  de  laryngol.,  etc., 

Par.,  191 1,  V.  I,  pp.  401-425. 
De  Sanctis,  S.     L'isterismo  di  guerra.     Riv.  ospedal.,  Roma.,  1917,  vii,  405-409. 
De  Sandro,  D.     II  mutismo  funzionale  da  scoppo  di  granata  e  quello  degli  isterici; 

loro  cura  con  I'eterizzazione.     Riv.  di  patol.  nerv.,  Firenze,   191 7,  v.  22, 

PP-  9-31-  .  .  ,.  . 

Deschamps,  Albert.     Un  symptome  fonctionnel  de  la  fatigue.     L  inversion  de 

la  sensation  de  fatigue.     Rev.  gen.  de  clin.  et  de  therap.,  Par.,  1916,  v.  30, 

pp.  262-264. 
Deserteur  ambulatoire.     Ann.  med.  psychol..  Par.,  1914-15,  p.  527. 
Descoust,  Paul.     Attitudes  vicieuses  du  pied  d'origine  nevropathique  dans  les 

traumatismes  du   membre  inferieur.     Presse   med..   Par.,    191 7,   v.   25,   pp. 

330-331- 

Desplates,  R.,  and  Buquet,  A.  Obliteration  des  arteres  des  membres  et  troubles 
circulatoires  des  nerfs.  L'ischemie  nerveuse  des  blesses  de  guerre.  Rev.  de 
med.,  Par.,  1916,  25,  578-619  (Published  in  February,  1918). 

Dessoir,    M.     Kriegspsychologische    Betrachtungen.     Leipz.,    1916,    S.    Hirzel, 

47  P-  8°. 
De  Tamowsky,  George.     Military  Surgery  of  the  Advanced  Zone.     No.  7,  Medi- 
cal Manual  War  Series.     Lea  and  Febiger. 
Detecting  the  pretense  of  deafness;   tests  adopted  in  France  to  reveal  the  tricks 

of  slackers.     Scient.  Am.  Suppl.,  N.  Y.,  1917,  Ixxxiii,  372. 
Devaux  et  Logue.     Les  delires  guerriers  dans  la  fievre  typhoide.     Presse  med., 

Par.,  191 5,  V.  23,  pp.  363-364- 
Devaux  et  Logue.     Les  anxieux.     1917,  Paris,  Masson  et  Cie.,  pp.  283-300. 
Dide,  W.  et  Lhermitte,  J.     La  diplegie  brachiale  spasmodique  consecutive  aux 

blessures  par  coup  de  feu  de  la  region  cervicale.     Progres  med.,  Par.,  1917, 

No.  I,  pp.  1-3. 
Diederich-Schwalbe.      Discussion,  Everth,  E.       Von  der  Stelle  des  Soldats  im 

Felde.       Rev.  in  Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  412, 

P-  1351- 
Die  behauptete  Zunahme  geistiger  Erkrankungen  bei  Beginn  des  Krieges  in  der 

Zivilvolkerung    Deutschlands.     Psychiat. -neurol.    Wchnschr.,    Halle    a.    S., 

1915-16,  V.  17,  No.  29-30,  131-132. 
Di  Pietro,   S.     Pneumotorace  curativo  o  pneumotorace  practicato  a  scopo  di 

simulazione  per  esenzione  dal  servisio  militare.     Ann.  di  clin.  med.,  Palermo, 

1916,  vii,  43-63. 
Discussion  of  Functional  Cases.     Proc.  Roy.  Soc.  Med.  Lond.,  1914-15,  v.  8, 

(sect,  laryngol.),  pp.  117-120. 
Discussion  on  Shell  Shock.     Lancet,  Lond.,  1916,  i,  p.  306. 
Discussion  on  the  treatment  by  physical  methods  of  mental  disabilities  induced 

by  the  war.      Proc.  Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10  (sect.  Balneol.), 

pp.  1-44. 
Discussion  sur  les  troubles  nerveux  dits  fonctionnels  observes  pendant  la  guerre. 

Rev.  neurol.,  Par.,  1914,  xxii,  447-452. 
Disordered  action  of  the  heart  among  soldiers.     Jour.  Lab.  and  Clin.  Med.,  1917, 

iii,  134. 
Disque.     Behandlung  der  Kriegsneurosen    durch  Hypnose,  Wachsuggestion  and 

suggestive  elektrische  Anwendungen.     Therapie  der  Gegenwart,  May,  1918. 


BIBLIOGRAPHY  925 

Dolger,  R.     Hysterische  Erkrankungen  des  inneren  Ohres  neben  allgem.  Hysteric 

nach  Granatenschlag  u.    Verschijssung.     Munch,   med.  Wchnschr,  nr.   16, 

1918. 
D'Oelsnitz.     L'adaptation  organique  des  territoriaux  k  la  guerre  actuelle.     Bull. 

et  mem.  soc.  med.  d'hop.  de  Par.,  1915-16,  v.  40,  pp.  1935-44. 
D'Oelsnitz,  M.  et  Boisseau,  J.     Note  sur  les  resultats  des  recherches  oscillo- 

metriques  pratiquees  dans  100  cas  de  mains  figees  et  27  cas  de  pieds  bots 

psychone\Tosiques.       Bull,  et  mem.  soc.  med.  d'hop.  de  Par.,  1917,  v.  33, 

pp.  1 1 47-1 149.  ^        ^    - 

Donald-Smith,  Helen.     War  distress  and  war  help;  short  catalogue  of  the  lead- 
ing war  help  societies.     Lond.  1917,  John  Murray,  38  p.  16°. 
Donath,  J.     Beitrage  zu  den  Kriegsverletzungen  und  Erkrankungen  des  Nerven- 

systems.     Wien.  klin.  Wchnschr.,  1915,  v.  28,  pp.  725-730,  and  pp.  763- 

766. 
Donath,  J.      Schwere  Polyneuritis  rheumatica  der  Plexus  brachiales  bei  einem 

Kriegsteilnehmer.     Wien.  klin.  Wchnschr,  Nr.  41,  S.  1291. 
Droiin.      Plaie  du  crane  par  eclat  d'obus.     Epilepsie  Jacksonnienne  et  hemi- 

paresie.     Cranioplastie  par  transplant  cartilagineux.     Resultats.   Jour,   de 

med.  de  Bordeaux,  1915-16,  v.  45,  pp.  241-242. 
Drouot,  E.     Pour  les  sourds  de  la  guerre;    reeducation  auditive,  lecture  sur  les 

levres,  orthophonie.     Rev.  scient.,  Par.,  191 5,  i,  pp.  363-367. 
Drug  Habit  and  Mobilization  in  France.     Lancet,  Lond.,  1915,  i,  p.  161. 
Dub.     Heilung     psychogenen     Taubheit     und     Stummheit.     Deutsche     med. 

Wchnschr.,  Berl.  u.  Leipz.,  1916,  No.  52,  pp.  1601-1602. 
Dubois,   Laumonier,   Bouquet,   Fiessinger,   Pardel.     Sur  I'angoisse  de  guerre. 

Bull.  gen.  de  therap.,  Par.,  1915-16,  v.  168,  pp.  821-828. 
Duco,  A.  and  Bliun,  E.     Guide  pratique  du  medecin  dans  les  expertises  medico- 

legales  militaires.     Collection  Horizon,  Masson  et  Cie,  Paris,  191 7. 
Ducoste.     Les  contractures  dans  les  lesions  nerveuses  peripheriques.     Compt. 

rend.  Soc.  de  biol..  Par.,  1915,  No.  14,  p.  435. 
Ducroquet.     L'ankylose  tibio-tarsienne  et  les  troubles  fonctionnels  consecutifs. 

Presse  med..  Par.,  1917,  v.  25,  pp.  561-564. 
Ducroquet.     Les  troubles  fonctionnels  dans  les  raideurs  et  les  ankyloses  dou- 

loureuses  de  1' articulation  tibio-tarsienne.     Presse  med.,  Par.,  191 7,  v.  25, 

PP-  597-599- 
Dufour,  Henri.     De  I'origine  infectieuse  de  certaines  hemiplegies  par  hemorrhagic 

et  ramollissement  cerebral.     Rev.  neurol..  Par.,  1917,  4.  24,  pp.  505-507. 
Dufour,  Henri,  et  Livy.     Neurasthenic  avec  troubles  de  la  nutrition  decelee  par 

I'examen  du  sang.     Presse  med..  Par.,  1917,  v.  25,  p.  323. 
Duken,  John.     Ueber  zwei  Falle  von  intrakranieller  Pneumatocele  nach  Schuss- 

verletzung.     Miinch.  med.  Wchnschr.,  1915,  v.  621,  pp.  598-599. 
Dumas.     Sur  les   accidents   nerveux  determines   par  la  deflagration   de  fortes 

charges  d'explosifs.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  593-595. 
Dumas,   R.     Liberation   des   nerfs   et   recuperation   fonctionnelle.     Bulletins  et 

Memoires  de  la  Soc.  de  chirurgie  de  Paris,  Feb.  8,  1916. 
Dumas,   G.  et  Aime,  H.     Les  troubles  mentaux  et  nerveu.x  dans  les    armees 

Austro-Allemandes.     J.  de  psychol.  norm,  et  path.,   Par.,   1915,  v.  2,  pp. 

329-347. 
Dumas,    G.   and  Delmas.     Les   confusions   mentales   d'origine  commotionnelle 

chez  les  blesses.     Arch,  de  med.  et  pharm.  mil..  Par.,  1917,  l.xvii,  69-77. 
Dumesnil,  Marius  A.     Delires  de  guerre.     Theses  de  Paris,  191 5-16,  v.  5,  No.  62. 
Dumesnil,  Marius  A.     Delires  de  guerre.     (Review.)     Ann.  d'hyg..  Par.,  1916, 

V.  26,  p.  183. 
Dumolard,  Rebierre  et  Quellien.     Inhibition,  variabilite,  instabilite  des  reflexes 

tendineux.     Rev.  neurol..  Par.,  1916,  v.  23,  pp.  139-142. 
Dumolard,  Rebierre  et  Quellien.     Reflexes  tendineux  variables.     Seule  mani- 
festation clinique  objective  d'un  etat  asthenique  grave.     Paris  med.,  1916, 

V.  21  (part,  med.),  pp.  286-288. 
Dumoz,  A.  G.     The  simulation  of  disease;    drugs,  chemicals,  and  septic  mate- 
rials used  therefor.     Pub.  Health  Rep.,  Wash.,  1917,  xxxii,  1887-1892. 
Dunlap,    Knight.     Psychologic   observations   and   methods.     Jour.    A.    M.    A., 

1918,  Ixxi,  1392. 


926 


BIBLIOGRAPHY 


Dunn,  Naughton.     Treatment  of  lesions  of  the  musculo-spiral  nerve  in  military 

surgery.     Amer.  Jour.  Orthop.  Surg.,  1918,  xvi,  258. 
Duplant,  A.  G.     Blessure  du  crane  datant  de  vingt  mois.     Abces  du  cerveau  a 

meningocoques.  Meningite  cerebrospinale.     Presse  med.,  Par.,  v.  24,  p.  366. 
Dupont,  J.  et  Troisier,  Jean.     Plaie  perforante  du  crane  dans  la  region  occipi- 

tale.     Polyurie,  dysphagie,  tachycardie  et  zona  cervical.    Guerison.     Bull. 

et  mem.  Soc.  med.  d'hop.  de  Par.,  1915,  v.  39,  pp.  21-28. 
Dupouy,  Roger.     Notes  statistiqueset  cliniques  sur  les  troubles  neuro-psychiques 

dans  I'armee  en  temps  de  guerre.     Ann.  med.-psychol.,  Par.,  1914-15,  v.  6, 

pp.  444-451-  

Dupouy,  R.     Note  sur  les  commotions  cerebro-medullaires  par  I'explosion  d'obus 

sans  blessure   exterieure.       Bell,  et  mem.  Soc.  med.  d'hop.  de  Par.,  1915, 

V.  39,  PP-  926-930- 
Dupouy,  R.     Commotion  cerebro-medullaire  par  eclatement  rapproclie.     Presse 

med.,  Par.,  1916,  v.  24,  p.  52. 
Dupouy  et  Bosc.     Troubles  cerebro-medullaires  par  explosion  de  mine.     Presse 

med.,  Par.,  1915,  v.  2T),  p.  330. 
Duprat,   G.  L.     La  psychotherapie  en  temps  de  guerre.     Progres  med.,   Par., 

1917,  No.  13,  also  No.  15,  pp.  123-125. 
Duprat,  G.  L.     Role  des  complexus  ideo-affectifs  et  de  I'onirisme  dans  les  syn- 
dromes emotionnels.     Progres  med..  Par.,  1917,  v.  43,  pp.  357-360. 
Dupre.     The  emotions  and  the  war.     War  Med.,  1918,  ii,  31. 
Dupre,  E.     Recherches  sur  les  symptomes  homolateraux  dans  les  perforations 

du  crane  et  de  I'encephale  par  projectiles  de  guerre.     Presse  med.,  Par., 

1916,  V.  24,  p.  174. 
Dupre,  E.     Reformes,  incapacites,  gratifications  dans  les  etats  psychopathiques 

de  guerre.     Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  790-799. 
Dupre,  E.     Discussion  de  la  conduite  a  tenir  vis-^-vis  des  blessures  du  crane  — 

par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  471. 
Dupre    et    Grimbert.     La  psychonevrose    emotive    constitutionelle  et  acquise. 

Rev.  neurol.,  Par.,  191 7,  v.  24,  pp.  45-48. 
Dupre,   E.,   et   LeFur.     Paraplegie   spasmodique   par  traumatisme   du   vertex. 

Rev.  neurol..  Par.,  1914-15,  v.  222,  p.  406. 
Dupre  et  Rist.     Hemiplegie  hysterique  chez  un  cuirassier.     Rev.  neurol..  Par., 

1914-15,  v.  22,  p.  200. 
DuRoselle  et  Oberthiir.     Sur  les  accidents  nerveux  determines  par  la  deflagra- 
tion de  fortes  charges  d'explosifs.     Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  598-605. 
Duroux,  E.  and  Couvreiu-,  E.     Resultats  eloignes  experimentaux  et  cliniques  des 

sutures  nerveuses.     Rev.  de  Chir.,  1917,  liii,  401. 
Dutheillet  De  Lamothe,  G.     Etude  sur  les  troubles  larynges  moteurs  dans  le 

paludisme.     Theses  de  Paris,  191 6-1 7,  Nr.  87. 
Dutton,  A.  S.     Beards  in  warfare.     Med.  Press  and  Circ,  Lond.,  1915,  v.  100, 

P-  520.  ... 

Duvemay,  L.  Contractures  post-traumatiques  en  chirurgie  de  guerre.  Paris 
med.,  1915,  V.  17  (part,  med.),  pp.  429-437. 

Dyakonoff,  P.  P.  (Cases  of  self-inflicted  injury  to  avoid  military  service.) 
Vestnik  Obshtsh.  Hig.,  Sudeb.  i  Prakt.  Med.,  Petrogr.,  1916,  v.  52,  pp.  1080- 
1082. 

Eager,  E.  War  psychoses  occurring  in  cases  with  a  definite  history  of  shell  shock. 
Brit.  Med.  Jour.,  1918,  i,  422. 

Ebel,  S.  Einige  Bemerkungen  iiber  physikalische  Therapie  der  Kriegskrankheiten. 
Ztschr.  f.  Phys.  u.  Diatet.  Therapie,  Leipzig.     1915,  v.  19,  pp.  182-190. 

Ebers,  E.  M.  Functional  Reeducation  and  Vocational  Training  of  Soldiers  dis- 
abled in  War.     Canad.  M.  Ass.  J.,  1917,  No.  3,  pp.  193-200. 

Edel.  Psycho-analytische  Behandlung  der  Hysteric  im  Lazarett.  Psychiat.- 
neurol.  Wchnschr.,  Halle  a  S.,  1916,  v.  17,  No.  2.  Rev.  Aerztl.  Runds- 
chau, Miinchen,  1916,  v.  26,  pp.  128-130. 

Edel,  K.  Krieg  und  Geisteskranken.  Neurol.  Centralbl.,  Leipz.,  1915,  v.  34, 
pp.  590. 

Edel,  M.  Neurosen  und  Psychosen.  Deutsche  med.  Wchnschr.,  1915,  v.  411, 
p.  30. 

Eder,  M.  D.  The  psychopathology  of  the  war  neuroses.  Lancet,  Lond.,  1916; 
ii,  pp.  264-268. 


BIBLIOGRAPHY 


927 


Eder,  M.  D.     War  Shock.     Philadelphia,  Blakiston  Son  &  Co.  and  Wm.  Heine- 

mann,  1917. 
Effects  of  high  explosives.     Jour.  A.  M.  A.,  1917,  Ixviii,  1182. 
Effect  (The)  of  the  war  upon  psychiatry  in  England.     Lancet,  Lond.,  1917,  ii,  352. 
Ehrmann.     Notiz   uber   die    Herztatigkeit    wahrend    Granatfeuers,     Ztschr.    f. 

Phys.  u.  Diatet.  Therap.  Leipz.,  1915,  v.  19,  p.  52. 
Elliott,  T.  R.     Transient  paraplegia  from  shell  explosions.     Brit.  M.  J.,  Lond., 

1914,  ii,  pp.  1005-1006. 
Emerson,  E.  B.     Mental  states  responsible  for  malingering.     Med.  Press,  Lond., 

191 7,  n.  s.,  civ,  433-436. 
EmsUe,  Isabel.     The  war  and  psychiatry.     Edinb.  M.  J.,  191 5,  v.  14,  p.  359. 
Engelen.     Beurteilung  der  Persuasion  (Unter  Bezugnahme  auf  die  Kriegsneu- 

rosen  und  Unfallsneurosen).     Aerztl.  sachv.  Ztg.  Berl.,  1915,  v.  2,  pp.  157- 

163,  and  pp.  171-175- 
Engelen   and   Rangette.     Nachweis   von   Simulation   durch    das   Assoziations- 

Experiment.     Aerztl.  Sachverst.-Ztg.,  Berl.,  1916,  v.  22,  pp.  37-40. 
Epstein,  L.     (The  war  and  psychoses.)     Gyogyaszat,   Budapest,   1915,  v.  55, 

pp.  40-43- 
Erben,   S.     Ueber   die   motorischen   Reizerscheinungen   bei   Kriegsteilnehmern. 

Wien.  klin.  Wchnschr.,  1916,  v.  29,  pp.  1129-1134. 
Erving,    William    G.      Orthopedic   treatment    of    nerve    lesions.     Amer.    Jour. 

Orth.  Surg.,  1918,  xvi,  346. 
Escat,  E.     Epreuve  des  diapasons   unisonnants  appliquee,  au  diagnostic  de  la 

surdite  unilaterale  simulee.     Presse  Med.,  Par.,  1916,  v.  24,  pp.  562-563. 
Eschbach,  H.  et  Lacaze,  H.     Meningite  cerebrospinale  debutant  par  des  troubles 

mentaux.     Bull,  et  mem.  Soc.  Med.  d'Hop.  de  Par.,  1915,  v.  39,  pp.  1024- 

1029. 
Esteve.     La  nostalgic  des  militaires.    Gaz.  med.  de  Par.,  1916,  v.  87,  pp.  122-123. 
Etats  anxieux.     Rev.  gen.  de  clin.  et  de  therap..  Par.,  1916,  v.  30,  pp.  89-90. 
Eugene,  V.     Paralysie  radiale  par  section  complete  du  nerf,  avec  perte  de  sub- 
stance de  3  centimetres  suture;    guerison  avec  recuperation  des  fonctions 

motrices  du  nerf.     Lyon  Med.  1916,  v.  125,  pp.  192-194. 
Evans,  J.  J.     Organic  Lesions  from  Shell  Concussion.     Brit.  M.  J.,  Lond.,  1915, 

ii,  pp.  848. 
Evans,  Jameson.     The  Peripheral  Lesions  of  Shell  Concussion.     Brit.  M.  J., 

Lond.,  1916,  i,  pp.  721. 
Everidge,  John.     Mental  symptoms  complicating  a  case  of  acute  tetanus  during 

treatment   by  carbolic   injections.     Brit.   M.  J.,  Lond.,   1916,  i,  pp.  443- 

444. 
Everth,  E.     Von  der  Seele  des  Soldaten  im  Felde.     Jena,  1915.     Rev.-Deutsche 

Med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  412,  p.  1351. 
Farrar,  Clarence  B.     Neuroses  among  returned  soldiers;   types  and  indications. 

Bos.  M.  &  S.  J.,  1918,  clxxix,  583,  615. 
Farrar,  C.  B.     War  and  neurosis,  with  some  observations  of  the  Canadian  Ex- 
peditionary Force.     Am.  J.  Insan.,  Bait.,  1917,  v.  73,  pp.  693-719. 
Farrar,  C.  B.     The  problem  of  mental  disease  in  the  Canadian  Army.     Mental 

Hyg.,  Concord,  N.  H.,  1917,  v.  i,  pp.  389-391. 
Farrar,  Clarence  B.     War  neuroses  and  psychoses.     x\mer.  Jour.  Med.  Sc,  1918, 

<=1^'  425- 
Fauntleroy.     Military   organization   and   equipment    in   the   present   war.     U. 

States  Nav.  M.  Bull.,  Wash.,  1916,  v.  10,  pp.  34-61. 
Faure,  J.  L.     Sur  les  tumeurs  provoquees  par  I'huile  camphoree.     Bull,  et  mem. 

Soc.  de  chir.  de  Par.,  191 7,  n.  s.,  xliii,  525. 
Faure,  Maurice.     La  reeducation  motrice  des  blesses  et  infirmes  de  la  guerre. 

Bull.  gen.  de  Th6rap.  Par.,  1916,  v.  168,  pp.  40-46. 
Fauser,  A.     Uber  dysglandulare  Psychosen.     Deutsche  med.  Wchnschr.,  Berl. 

u.  Leipz.,  1916,  No.  2,  pp.  47-49- 
Fazio,  F.     La  cura  del  mutismo  psicoisterico  dei  militari  combattenti.     Med. 

prat.,  NapoH,  1916,  v.  i,  pp.  371-373- 
Feamsides.      Wassermann  reaction  in  shell  shock.      Proc.    Roy.   Soc.   Med., 

London.,  (Sec.  of  Neurol.),  1915-16,  v.  9,  pp.  39-41. 
Feilchenfeld,  Hugo.       Ein  objektives  Symptom  zur   Priifung  der   Nachtblind- 

heit.     Berl.  KUn.  Wchnschr.,  1916,  No,  44,  pp.  1195-1196. 


928  BIBLIOGRAPHY 

Feilchenfeld,  und  Bauer.     Kriegsblinden  Fiirsorge.     Deutsche  med.  Wchnschr., 

Leipz.  u.  Bed.,  1916,  v.  42,  pp.  1324. 
Felling,  Anthony.     Loss  of  personality  from  shell  shock.     Lancet,  Lond.,  1915, 

ii,  pp.  63. 
Fellner,  B.    Fall  von  echter  Katatonie  (Mahren).     Wien.  med.  Wchnschr.,  1915, 

No.  30,  pp.  1 1 55. 
Felzmann.     (War  psychoses).     J.  Neuropath,  i.  Psikhiat.,  Korsakova,  Mosk., 

1915.  V.  15,  No.  4. 
Fenwlck,  P.  C.  C.     Entero-spasm  following  shell  shock.     Practitioner,  Lond., 

1917,  s.  xviii,  391. 
Femfindez  Sanz.     Contribucion  a  la  psiquiatria  de  la  guerra;    comentarios  al 

determinismo  causal  y  a  la  sintomatolgia  de  la  psicosis  de  origen  belico. 

Rev.  clin.  de  Madrid,  1915,  v.  13,  pp.  121-131. 
Fernet,  Charles.     De  la  surdite  et  de  son  traitement  par  I'activite  fonctionelle. 

J.  de  Med.  et  de  chir.,  1915,  v.  86,  Apr. 
Fernet,  Charles.     De  la  gymnastique  oculaire  et  de  son  application  k  I'education 

de  la  vue  et  au  traitement  de  la  myopie  et  de  la  presbyopie.     J.  de  Med.  et 

chir.  prst..  Par.,  1916,  v.  87,  pp.  I53-I57- 
Ferrand,    J.     Reflexions   medicochirurgicales  sur   la   pratique   neurologique  en 

temps  de  guerre.     J.   de  radiol.  et  d'electrol.,  Par.,   1914-15,  i,  pp.  629- 

639- 
Ferrand,   Jean.     Aphasie  avec  hemiplegie  gauche  par  ligature  de  la  carotide 

primitive  droite.     Paris  Med.,  1916  (Part.  Med.),  v.  19,  pp.  537-540. 
Ferrand,  J.     Y-a-t-il  des  hystero-traumatismes  differents  en  temps  de  paix  et 

en  temps  de  guerre?     Rev.  de  med..  Par.,  1916,  v.  35,  pp.  239-275;   and  pp. 

293-313- 
Ferrand,  Jean.     Y-a-t-il  des  hystero-traumatismes  differents  en  temps  de  paix 

et  en  temps  de  guerre?     Rev.  de  med.,  mai-juin,  1917,  Rev.  Progres  med., 

Par.,  1917,  V.  43,  pp.  356-357-. 
Ferrand,   Jean.     Hystero-traumatismes  avec  syndrome  dit  "  physiopathique  " 

gueri  par  la  reeducation.     Progres  med..  Par.,  1917,  No.  10,  pp.  81-83. 
Ferrand,  Jean.     De  I'unite  clinique  et  pathogenique  de  tons  les  hystero-trau- 
matismes.    Paris  med.,  1917,  No.  24,  pp.  509-512. 
Ferrannini,  L.     La  rieducazione  professional  degli  invalidi  della  guerra.   Riforma, 

med.,  Napoli,  191 7,  v.  33,  pp.  347-349- 
Ferrie,   Jean  L.      Contribution  k  I'etude  des  voyages  pathologiques  chez  les 

alienes  militaires.     Theses  de  Paris,  1915,  v.  5. 
Feulllade.     Sur  les  accidents  nerveux  determines  par  la  deflagration  de  fortes 

charges  d'explosifs.     Rev.  neurol.  Par.,  191 6,  v.  29,  pp.  591-592. 
Fiessinger,  Ch.     Le  role  psychologique  du  vin.  Bull.  Acad,  de  med..  Par..  No.  8, 

fer.  1916.     Paris  Med.,  1916  (Part.  Med.),  v.  19,  p.  210. 
Fiessinger,  Noel.     Choc  emotionnel  par  explosion  d'obus  de  gros  calibre.     Rev. 

gen.  de  clin.  et  de  therap.,  1915,  v.  29,  pp.  99-100. 
Fiessinger,  Noel.     Emotional  Shock.     Med.  Press  and  Circ,  Lond.,  1915,  v.  99, 

P-  563- 
Fischer,  H.     Six  months  of  war  surgery  in  a  base  hospital  in  Germany.     Am.  J. 

Surg.,  N.  Y.,  1917,  V.  31,  pp.  4-10. 
Fischer,  H.     Gunshot  injuries  of  the  peripheral  nerves  and  their  treatment. 

Ann.  of  Surg.,  191 7,  Ixv,  56. 
Fischeri  M.     Die  Erwerbsfiirsorge  fiir  Kriegsinvalide  an  unseren  Heil-  und  Pfle- 

geanstalten.  Psych,  neurol.  Wchnschr.,  Halle  a.  S.,  1915,  v.  16,  p.  420. 
Flesch,  J.     Ueber  sogen.  funktionelle  Nervenerkrankungen.     Psychiatr.-neurol. 

Wchnschr.,  20,  1918-9. 
de  Flines,  E.  W.     Doofheid,  simulatie  en  dissimulatie.     Mil.-geneesk.  Tijdschr., 

Haarlem,  1917,  xxi,  124-133. 
Flusser,  E.     Uber  Psychosen  beim  Kriegstyphus.     Wien.  med.  Wchnschr.,  1915, 

V.  65,  No.  297. 
Foix,  Ch.     Contribution  a  I'etude  de  I'apraxie  ideo-motrice,  de  son  anatomic 

pathologique  et  de  ses  rapports  avec  les  syndromes  qui  ordinairement  I'ac- 

compagnent.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  283. 
FolgezustSnde.     Lfber  durch  der  Krieg  bedrohte  Folgezustande  am  Nervensystem. 

Berl.  klin.  Wchnschr.,  1915,  v.  42,  p.  277. 
Forgues.     Maladies  simulees.     Caducee,  Par.,  1915,  v.  15,  pp.  132-133. 


BIBLIOGRAPHY  929 

Forster.     Der  Krieg  und  dfe  traumatischen  Neurosen.  Monatschr.  f.  Psychiat.  u. 

Neurol.,  Berl.,  1915,  v.  37,  pp.  72-75. 
Forster,  Frederick  C.     Management  of  neurasthenia,  psychasthenia,  shell-shock, 

and  allied  conditions.     Practitioner,  1918,  c.  85. 
Forsyth,  David.     Functional  nervous  disease  and  the  shock  of  battle:  a  study  of 

the  so-called  traumatic  neuroses  arising  in  connection  with  the  war.     Lancet, 

Lond.,    1915,   ii,    pp.    1399.       (See   also   Mercier,   Lancet,   Lond.,   1916,    i, 

V-  I54-) 
Fortineau,  Louis.     Quelques  cas  de  delire  onirique  observes  au  cours  de  la  fievre 

typhoide.     Presse  Aled.,  Par.,  1915,  v.  23,  p.  225. 
Fcucault,  Prof.     Experiences  sur  la  fatigue  mentale.     Rev.  phil.,  Par.,  191 5,  v. 

79.  PP-  505-526. 
Fox,  R.  Fortescue.     Model  hydrotherapeutic  installation  for  soldiers  with  ground 

plan.     J.  Roy.  Army  Med.  Corps,  Lond.,  1916,  v.  26,  pp.  660-664.     Also, 

The  "  sedative  pool  bath  "  —  Lancet,  Lond.,  1916,  v.  ii,  p.  302. 
Fox,  R.  Fortescue.     Physical  remedies  for  disabled  soldiers.     Lond.,  1917,  Bail- 

liere,  p.  287,  8°. 
Frani.     Krieg  und  arztliche  Sachverstandigentatigkeit.     Arztl.  Sachverst.  Ztg., 

Bed.,  1914,  No.  23,  pp.  434-436. 
Fraser,  J.  S.     War  Injuries  of  the  Ear.     Edinb.,  M.  J.,  1917,  p.  107. 
Fraser,  J,  S.  and  John.     The  Morbid  Anatomy  of  War  Injuries  of  the  Ear. 

Proc.  Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10  (see  Otol.),  pp.  56-90. 
French  wounded  from  some  early  actions.     Brit.  M.  J.,  Lond.,  1914,  ii,  p.  853- 

854- 
Frenkel,  H.     L'hemeralopie  chez  les  mobilises  de  I'interieur.     Arch,  d'opht.,  Par., 

1917,  V.  35,  pp.  577-579- 
Freud,  Sigmund.     Zeitgemasses  iiber  Krieg  und  Tod.     Imago,  Leipz.,  and  Wien., 

1915,  V.  4,  pp.  1-21. 
Frey,  Hugo  and  Selye,  Hugo.     Beitrage  zur  Chirurgie  der  Schussverletzungen 

des  Gehirns.     Wien.  klin.  Wchnschr.,  1915,  v.  28,  pp.  722-724. 
Friedlander,  A.     Nerven-und   Geisteskrankheiten  im  Felde  und  im    Lazarett. 

Wiesb.,  1 9 14  (J.  J.  Bergmann),  p.  39,  8°. 
Friedlander,   R.    Julius.     Zerebellare  Symptomenkomplexe  nach   Kriegsverlet- 

zungen.  Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  p.  813. 
Friedmann.     Zur  Auflfassung  die   gehauftigten  kleinen  Anfalle.     Monatschr.  f. 

Psychiat.  u.  Neurol.,  Berl.,  1915,  v.  38,  p.  76. 
Froderstrom,  H.     (Neurological  impressions  (May,  191 6)  from  a  travel  report  to 

the  chief  of  the  naval  medical  department.)     Tidskr.  i  mil.  Halsov.,  Stock- 
holm, 1917,  V.  42,  pp.  137-149. 
Froment,  J.     Paraplegie  par  deflagration  d'obus.     Rev.  neurol.,  Par.,  1914,  v.  22, 

PP-  754-755- and  pp.  1205-1214. 
Froment,  J.     Du  pronostic  de  I'aphasie  traumatique  consecutive  aux  plaies  du 

crane  par  armes  a  feu.     Lyon  chirurg.,  1916,  v.  13,  pp.  434-447. 
Froment.     La  prehension  dans  les  paralysies  du  nerf  cubital  et  le  signe  du  pouce. 

Presse  med.,  Oct.  21,  1915. 
Fuchs,    W.     Mobilmachungspsychosen.     Aerztl.     Sachverst. -Ztg.,    Berl,,    1915, 

xxi,  25-29. 

Functional  cardiac  disorders  in  soldiers.     J.  Am.  M.  Ass.,  Chicago,  1917,  v.  69, 

p.  202. 
Fvirbush,  Edith  M.     Mental  disease,  suicides  and  homicides  in  the  United  States 

Army  and   Navy,    1897-19 15,   prepared  from  the  Annual  Reports  of  the 

Surgeons-General.     Mental  Hyg.,  Concord,  N.  H.,  1917,  i,  406-408. 
Fu^rther  Extension  of  Second  Eastern  General  Hospital,  Brighton.     Brit.  M.  J., 

Lond.,  1915,  i,  p.  908. 
GaUlard.     Tachypnoe   hysterique   chez   un   militaire.     Bulletins   de  la   Societe 

Medicale  des  Hopitaux  de  Paris,  30  decembre  191 5. 
Garbo.     A  propos  du  choc  gazeux  cause  par  I'explosion  des  obus.     Wien.  Klin. 

Woch.,  No.  4,  1915. 
Garrod,  A.  E.     War  heart,  which  calls  for  treatment  by  complete  rest.     Lancet, 

Lon.,  1917,  i,  985. 
Garton,  W.     Shell  shock  and  its  treatment  by  cerebrospinal  galvanism.       Brit. 

Med.  Jour.,  1916,  ii,  584. 


930  BIBLIOGRAPHY 

Garton,  Wilfrid.     Shell  shock  and  its   treatment   by   cerebrospinal   galvanism. 

Brit.  M.  J.,  191 6,  V.  ii,  pp.  584-586. 
Gate,  J.  et  M.  Dechosal.     Menir»gite  cerebro-spinale  k  pseudomeningocoque. 

Lyon  Med.,  1916,  v.  125,  pp.  349-352- 
Gaucher  et  Renee  E^ein.     Le  psoriasis  emotif  et  traumatique.     Paris  med.,  1916, 

(Part.  Med.),  v.  18,  pp.  428-430. 
Gaupp,  R.     Granatkontusion.      Bruns.   Beitr.   96   H.   3.    Rev.    Deutsche    med. 

Wchnschr.,  1915,  v.  412,  pp.  811-812. 
Gaupp,  R.     Hysteric  und  Kriegsdienst.     Miinch.  med.  Wchnschr.,  1915,  v.  62, 

pp.  361-363- 
Gaupp,  R.     Ungewohnliche  Formen  der  Hysteric  bei  Soldaten.     Miinch.  med. 

Wchnschr.,  1915,  v.  33,  p.  11 19. 
Gaupp,    R.     Ungewohnliche    Formen    der    Hysteric    bei    Soldaten.     Psychiat. 

Neurol.  Wchnschr.,  Halle,  a.  S.,  1915-16,  v.  17,  p.  256.  ^ 

Gaupp,  R.     Die  Granatkontusion.  Beitr.  z.  klin.  Chir.,  Tiibing.,   1915,  v.  96     , 

pp.  277-294. 
Gaupp,  R.     Die  Granatkontusion.     Centralbl.  f.  Chir.,  Leipz.,  1915,  v.  42^  pp. 

429-430. 
Gaupp,  R.     Die  Diensbrauchbarkeit  der  Epileptiker  und   Psychopathen.     Die 

militararztliche   Sachsverstandigentatigkeit   auf   dem   Gebiete    des    Ersatz- 

wesens  und  der  miUtarischen  Versorgung.     Erste  Teil.,  pp.   1 15-139.   Jean 

Fischer,  191 7. 
Gautrelet,  J.     Les  bases  scientifiques  de  I'education  professionnelle  des  mutiles. 

Bull.  Acad,  de  Med.,  Par.,  1915,  v.  73,  pp.  663-668. 
Geigel.     Nervoses  Herz  und  Herzneurosen.     Miinch.  Med.  Wchnschr.,  191 7,  No. 

I,  PP- 30-32. 
Gennerich,  W.     Die  Ursachen  von  Tabes  und  Paralyse.     Monatschr.  f.  Psychiat. 

u.  Neurol.,  Berl.,  1916,  v.  39,  No.  6,  p.  341. 
Gerhardt.     Uber  Herzstorungen   im   Kriege.     Miinch.,  med.  Wchnschr.,   1915, 

V.  34',  p.  II74- 
Gerhardt.     Hysterische  Paraplegic.     Miinch.  med.  Wchnschr.,  1915,  v.  34^,  pp. 

1763- 
Gerstmann.     Hemianopie  durch  Contrecoup  nach  Schussverletzung.  Klin,  therap. 

Wchnschr.,  Wien.  u.  Berl.,  1916,  v.  33^  p.  29. 
Gerver,  A.  V.     (A  study  of  statistics  of  mental  diseases  in  the  army  in  time  of 

war.)     Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  158-165. 
Gerver,  A.  V.     (Mental  diseases  in  the  theatre  of  war.)     Russk.  Vrach.,  Petrogr., 

1915,  V.  14,  p.  793;  p.  817;  p.  841. 
Gerver,  A.  V.     (Traumatic  neuroses  among  soldiers).     Russk.  Vrach.,  Petrogr., 

1915,  V.  14,  pp.  937-944;  and  pp.  967-972. 
Gerver,  A.  V.     (Neurasthenia  and  influence  of  the  war  on  its  symptomatology.) 

Russk.  Vrach.,  Petrogr.,  1916,  v.  15,  p.  220;    p.  241. 
Giachetti,  C.     I  caratteri  e  la  guerra.     Riv.  di  psicol.,  Bologna,   1916,  v.   12, 

pp.  301-316. 
Giannelli,  A.     Le  malattie  mentali  e  nervosi  in  guerra.      Riv.  ospedal.,  Roma, 

1915.  V.  5,  pp.  322-331- 
Giannuli,  F.     Le  syndrome  Korsakoff  et  la  commotion  cerebrale.     Rivista  speri- 

mentale  di  Freniatria,  vol.  XL,  fasc.  2,  30  juin  1914. 
Gibt  es  eine   "  Kriegspsychose? "      Psychiat.  Neurol.  Wchnschr.  Halle  a.  3., 

1914-1915,  V.  6,  pp.  356-357- 
Gilbreth,  F.  B.     The  problem  of  the  crippled  soldier;    how  to  put  him  on  the 

payroll.     Scient.  Am.  Suppl.,  N.  Y.,  1917,  v.  83,  p.  260. 
Gilbreth,  F.  B.  and  Gilbreth,  Lillian  M.     The  conservation  of  the  world's  teeth; 

a  new  occupation  for  crippled  soldiers.     Trained  nurse  (etc.),  N.  Y.,  1917, 

V.  59,  pp.  5-1 1- 
Gilchrist,  Norman  S.     Analysis  of  causes  of  breakdown  in  flying:    with  notes 

on  the  nervous  mechanism  of  the  flying  man.     (Ref.  lost.) 
Gilles,  Andre,     fitude  sur  certains  cas  de  neurasthenic.     Ann.  med.-psychol.. 

Par.,  1916,  1917;   V.  73,  pp.  209-229;   and  pp.  333-364. 
Gilles,  Andre.     L'hysterie  et  la  guerre  troubles  fonctionnels  par  commotion. 

Leur  traitement  par  le  torpillage.     Ann.  med.  psychol.  Par.,  191 7,  v.  73, 

pp.  207-227. 


BIBLIOGRAPHY 


931 


Gillet,  H.  et  Boye,  G.     Les  insuffisants  cardiaques.     Paris  med.,  1916    v    t 

PP-  30-33-  '  ' 

Gilyarovski,  V.  A.     (The  war  and  the  care  of  the  insane  in  time  of  peace  ) 

Sovrem.  Psikhiat.,  Mosk.,  1915,  v.  9,  pp.  287-297. 
Gilyarovski,  V.  A.     (Nature  of  alterations  in  the  neuropsychic  sphere  after  war 

contusions.)     Sovrem.  Psikhiat.,  Mosk.,  1916,  v.  10,  pp.  403-433. 
Ginestous,  E.     L'indice  visual  d'aptitude  au  service  militaire.     Arch,  de  med   et 

pharm.  mil..  Par.,  1914-15,  v.  64,  pp.  718-24. 
Ginestous,  Etienne.     Blepharospasme  tonique  hystero-traumatique.     Gaz   med 

de  Par.,  1915,  v.  14,  pp.  61-62. 

Ginestous,  E.     L'armee  frangaise  perd  20,000  astigmates.     Caducee   Par     tot? 
v.  15,  p.  99.  •.    y  0, 

Ginestous,  E.     Hemianopsie  en  quadrant.     Progres   med.,   Par      iqi6    v    t 

pp.  3-4-  '     y     '         o  , 

Gino,  S.  and  Stefano,  B.     Mutismo  isterico  consecutivo  a  scoppio  di  granata  in 

sogetto  istero-epilettico.     Gazz.  d.  osp.,  Milano,  1917,  v.  38,  pp.  308-^10 
Giroux.     Hemiplegie  consecutive  a  une  intoxication  par  les  gaz  asphyxiants 

Rev.  Paris  med.  1916.  (Part.  Med.),  v.  21,  p.  436. 
Glaser,      W.     Diphtheriebazillen      als      Meningitiserregen.     Munchen.      med 

Wchnschr.,  1917,  64,  856-57. 
Glieboff,  D.  A.     (Malingering  by  recruits.)    Sibirsk.  Vrach.,  Tomsk,  19 15,  i,  4,  49, 

Goddard,  H.  HL     The  place  of  intelligence  in  modern  warfare.     U.  S.  Nav.  M. 

Bull.,  Wash.,  1917,  v.  9,  pp.  283-289. 
Goetjes.     Ueber     Gehirnverletzungen    durch     Granatsplitter.      Munch,     med. 

Wchnschr.,  1915,  v.  62,  pp.  897-898. 
Goissard,  Liebault.     Les  aphones  pendant  la  guerre.     Archiv.  de  Med.  et  de 

Pha.  Mil.,  1916,  V.  66,  No.  i  or  No.  3;  p.  169. 
Golant,  R.  Ya.     (Neurotic  symptoms  in  soldiers).     Obozr.   Psikhiat.,   Nevrol. 

Petrogr.,  1916,  v.  20,  pp.  63-66.  '  ' 

Goldscheider.     Zur  Frage  der  traumatischen  Neurose.    Deutsche  med.  Wchnschr., 

Berl.  u.  Leipz.,  1916,  v.  42,  No.  46. 
Goldsmith.     Special  Discussion  on  Warfare  Injuries  and  Neuroses.     Proc.  Roy. 

Soc.  Med.,  Lond.,  1917,  v.  10  (sec.  Octol.),  pp.  1 19-122. 
Goldstein,-   K.     Die   militarische   Sachsverstandigentatigkeit   auf   dem   Gebiete 

des  Ersatzwesens  und  der  militarischen  Versorgung  bei  de  Hirnverletzungen. 

Erste  Teil,  pp.  194-232.  Jena,  Fischer,  1917. 
Goldstein.     Beobachtungen  an  Schussverletzungen   des   Gehirns   und   Riicken- 

marks.     Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41,  pp.  215-217. 
Goldstein.     Die  Suggestionstherapie  der  funktionellen  neurosen  im  Feldlazarett. 

Therapie  der  Gegenwart,  Sept.,  1917. 
Goldthwaite,  J.  E.     The  place  of  orthopedic  surgery  in  war.     Am.  J.  Orthop. 

Surg.,  Bost.,  191 7,  V.  15,  pp.  679-686. 
Gonda,  Viktor.     Rasche  Heilung  der  Symptome  der  im  Kriege  entstandenen 

traumatischen  Neurosen.     Wien.  klin.  Wchnschr.,  1916,  v.  29,  No.  30. 
Goodwin,  T.  H.     No.  2,  Notes  for  Army  Medical  War  Officers.     Medical  Manual 

War  Series.     Lea  and  Febiger,  191 7. 
Gordon,  W.,  Sunderland,  S.  {et  al).     Physical  treatment  for  disabled  soldiers. 

Lancet,  Lond.,  1917,  v.  i,  p.  348. 
Goria,  C.     Alcune  considerazioni  attonio  al  mutismo  psichico  nei  militari  alia 

sua  genesi  emozionale  e  commozionale.     Riform.  med.,  Napoli,  1916,  v.  32, 

pp.  725  and  756. 
Gosset,  H.     Contribution  a  I'etude  experimental  du  controle  auditif.     Progres 

med.,  Par.,  1916,  No.  i,  pp.  21-22. 
Gosset,  H.     Traitement  des  impotences  consecutives  aux  blessures  de  guerre 

par   la   reeducation    psycho-motrice.     Progres    Med.,    Par.,    1916,    No.    3, 

PP-  35-38. 
Gosset,   H.     La  reeducation   de  I'appareil   locomoteur.     Progres    Med.,    Par., 

1916,  No.  3,  pp.  65-70. 
Gosset,  H.     Experiences  relatives  au  controle  auditif.     Progres.  Med.  Par.,  1917, 

No.  2,  pp.  9-10. 
Gouget,  A.     La  bradycardie  de  fatigue.     Bull.  Acad,  de  Med.,  Par.,  1915,  v.  74, 

pp.  810-812. 


932  BIBLIOGRAPHY 

Gouget.     Un  cas  de  neuro-fibromatose.     Presse  Med.,  1916,  v.  24,  p.  309. 
Gougerot,  H.  and  Charpentier,  Albert.     Paralysies  reflexes  troubles  trophiques 

reflexes   consecutifs   aux   blessures   des   extremites.      Ann.   de   med.,    Par., 

1916,  V.  3,  pp.  269-297. 
Grace,  J.  J.     A  note  on  the  electrical  treatment  of  disabilities  due  to  wounds. 

Brit.  M.  J.,  Lond.,  1915,  ii,  p.  812. 
Gradenigo,   G.     Esagerazione  e  simulazione  della  sordita  nei  militari.     Arch. 

ital.  di  otol.  Torino,  1916,  v.  27,  pp.  139-147. 
Gradenigo.     Mutismo,  afonia,  sordita  nei  militari:    di  origine  psichica,  de  cause 

organiche:    simulazioni  e  criteri  diff^erenziedi  obiettive.     Riv.  di  patol.  nerv. 

Firenze,  1917  (March). 
Graham,  W.     War  and  the  incidence  of   insanity.     Med.  Officer,  Lond.,  1916, 

V.  16,  p.  453. 
Granjux.     La  faillite  de  instruction  sur  I'aptitude  physique  au  service  mili- 

taire.     J.  de  med.  et  chir.  prat..  Par.,  1915,  v.  86,  pp.  849-853. 
Granjuz.     De  la  necessite  des  services  de  psychiatric  et  de  medecine  legale  aux 

armees.     Caducee.  Par.,  1916,  xvi,  43-45. 
Granjuz.     Les   conditions   dans   lesquelles   seront   pratiquees   les   expertises   en 

matiere  d'accidents  du  travail  dont  seront  victimes  les  mutiles  de  la  guerre. 

Soc.  med.  leg.  de  France,  Bull.,  Par.,  1917,  v.  14,  pp.  221-222. 
Grant,   Dundas.     Mutism,   stammering,    psychical   deafness.     Proc.   Roy.   Soc. 

Med.,  Lond.,  1915-16,  v.  9  (sect.  Psychiat.)  pp.  37-38. 
Grant,  D.     Special   discussion  on   warfare   injuries  and   neuroses.     Proc.  Roy. 

Soc.  Med.,  Lond.,  1917,  v.  10  (sec.  Otol.),  pp.  93-96. 
Grasset.     Clinical  lectures  on  the  psychoneuroses  of  war.  (2  papers).      Med. 

Press  and  Circ,  Lond.,  1915,  i,  v.  99,  pp.  560-563;   and  pp.  586-587. 
Grasset.     Le   traitement    des   psychonevroses   de   guerre.     Presse   med.,    Par., 

1915,  V.  23,  pp.  105-108;   and  p.  425. 
Grasset.     Les  psychonevroses  de  guerre.     Presse  medicale,  i  avril,  1915. 
Grasset.     Les  nevroses  et  psychonevroses  de  guerre;    conduite  a  tenir  a  leur 

egard.     Rev.  neurol..  Par.,  1916,  xxiii,  767-774.     (Discussion)  774-788. 
Grasset.     Les  symptomes  atypiques  a  developpement  tardif  dans  les  trauma- 

tismes  cranio-cerebraux.     Montpel.  med.,  1916,  v.  39,  p.  19. 
Grasset.     Les  maladies  de  guerre  du  systeme  nerveux  et  les  conseils  de  reforme. 

Presse  med.  Par.,  191 6,  v.  24,  pp.  1-2. 
Grasset.     Les   grands  types   cliniques   des   psychonevroses   de   guerre.       Rev. 

neurol.  Par.  1917,  v.  24,  p.  471. 
Grasset.     Les  grandes  types  cliniques  de  psychonevroses  de  guerre.     Montpel. 

med.,  1917,  n.  s.,  v.  39,  pp.  607-628. 
Grasset  et  Maurice  Villaret.     A  propos  de  pronostic  tardif  des  traumatismes 

cranio-cerebraux.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  833-834. 
Gray,  H.  M.  W.     Gunshot  wounds  of  the  head.     Brit.  Med.  Jour.,  1916,  i,  261. 
Green,  Edith  M.  N.     Blood  pressure  and  surface  temperature  in  no  cases  of 

shell  shock.     Lancet,  Lond.,  191 7,  ii,  pp.  456-457. 
Greenlees,   T.    D.      The   war;     impressions,    neuro-   and   psychological.     Med. 

Press  and  Circ,  Lond.,   1916,   n.   s.,  v.    loi,  pp.    101-103;    ^Iso  Caledon. 

M.  J.,  Glasg.,  1915-16,  No.  10,  pp.  183-187. 
Gregor.     Granatenkontusion   mit    ausgedehntem  amnestichen    Defekt.  Miinch. 

med.  Wchnschr.,  1915,  v.  62",  p.  1055. 
Grenier   de    Cardenal,   Legrand,   Benoit.      Trois   nouveaux   cas   de   rage   chez 

I'homme.     Presse  med..  Par.,  191 7,  v.  25,  pp.  564-566. 
Griffith,  A.  D.     Injuries  of  the  eye  and  orbit.     Lancet,  Lon.,  1916,  i,  1245. 
Grivot,  M.     Appareil  auditif  et  traumatismes  de  guerre.     Paris  med.,  1915,  v.  17, 

PP-  359-365- 
Grober.     Die  Krankheiten  der  Kreislauforgane  und  der  Krieg.      Miinch.  med. 

Wchnschr.,  1914,  ii,  v.  61,  pp.  2388-2390. 
Gross,    C.     Nervose   iM-iegsdienstschadigungen.     Wien   klin.    Wchnschr.,    1916, 

xxix,  1577. 
Griinbaum,    F.       Hysterie     und    Kriegsdienstbeschadigung.       Deutsche    med. 

Wchnschr.,  Berl.  u.  Leipz.,  1916,  v.  42,  pp.  1452-1453. 
Griinwald.     Schussverletzungen   der  pneumatischen  Schadelhohlen.      Miinchen 

med.  Wchnschr.  191 5,  v.  62S  pp.  823-825. 


BIBLIOGRAPHY  933 

Grutzhaendler-Inddson.  Troubles  sensitivomoteurs  hysterotraumatiques  ob- 
serves a  I'occasion  de  la  guerre  1914-1915.     These  de  Paris,  191 5. 

Gudden.  Beginnende  Behandlung  psychischer  Erkrankungen  im  Felde.  Miin- 
chen  med.  Wchnschr.,  1915,  v.  62,  pp.  1730. 

Guepin,  A.  Dix  cas  de  chirurgie  cerebrale.  Caducee,  Par.,  1916,  v.  16,  pp. 
74-77. 

Guerre  et  les  eclopes  psychiques.     Ann.  d'Hyg.,  Par.,  1917,  v.  25,  pp.  252-254. 

Guilbert,  Charles  and  Maucurier,  G.  Guide  de  reeducation  physique  en  groupe. 
Methode  de  gymnastique  reeducative  pour  les  blesses  militaires.  Par.,  1916, 
J.  B.  Bailliere  et  fils.     128  pp.,  12°. 

Gtiild,  S.  R.  War  deafness  and  its  prevention;  a  critical  review.  J.  Lab.  and 
Clin.  M.,  St.  Louis,  1916-17,  v.  2,  pp.  849-861. 

Guillain,  G.  Un  cas  de  contractures  generalisees  avec  sympt6mes  meninges  con- 
secutive a  I'eclatement  d'un  projectile  sans  plaie  exterieure.  Presse  Med., 
Par.,  1915,  V.  23,  p.  181. 

Guillain,  G.  Les  crises  epileptiques  consecutives  a  1'  explosion  des  projectiles 
sans  plaie  exterieure.     Presse  med.,  Par.,  1915,  v.  23,  pp.  181. 

Guillain,  G.  Sur  un  cas  de  mutisme  consecutif  a  I'eclatement  d'un  projectile. 
Presse  Med.,  Par.,  1915,  v.  23,  p.  182. 

Guillain,  G.  Un  cas  de  tremblement  pseudo-parkinsonien  consecutif  a  I'eclate- 
ment d'un  projectile  sans  plaie  exterieure.  Presse  Med.,  Par.,  1915,  v.  23, 
p.  182. 

Guillain,  G.  Les  syndrSmes  paralytiques  consecutifs  a  I'eclatement  des  pro- 
jectiles sans  plaie  exterieure.     Presse  med.  Par.,  1915,  v.  23,  pp.  225-226. 

Guillain,  G.  Le  syndrome  cerebelleux  a  type  de  sclerose  en  placques  consecutif 
a  I'eclatement  des  projectiles  sans  plaie  exterieure.  Presse  med..  Par., 
1915,  v.  23,  p.  226. 

Guillain,  G.  Sur  un  etat  de  stupeur  avec  catatonie,  hypothermie,  bradycardia 
et  hypopnee  consecutif  k  I'eclatement  d'un  projectile  sans  plaie  exterieure. 
Presse  med..  Par.,  1915,  v.  23,  p.  226. 

Guillain,  G.  Les  nevrites  irradiantes  et  les  contractures  et  paralysies  trauma- 
tiques  d'ordre  reflexe.     Soc.  med.  des  Hopitaux,  26  mai  1916. 

Guillain,  G.  Sur  un  syndrome  choreiforme  consecutif  a  I'eclatement  d'un  pro- 
jectile sans  plaie  exterieure.     Presse  med..  Par.,  1915,  v.  23,  p.  225. 

Guillain,  G.  Hemiplegie  organique  consecutive  a  un  eclatement  d'obus  sans 
plaie  exterieure.     Presse  med..  Par.,  1915,  v.  23,  p.  429. 

Guillain,  G.  Influence  sur  le  systeme  nerveux  des  eclatements  d'obus  de  gros 
calibre.     Rev.  gen.  de  clin.  et  de  therap..  Par.,  1915,  v.  29,  p.  736. 

Guillain,  G.  Sur  les  accidents  nerveux  determines  par  la  deflagration  de  fortes 
charges  d'explosifs.     Rev.  neurol.  Par.,  1916,  v.  29,  pp.  576-577. 

Guillain,  G.  Un  syndrome  consecutif  a  I'eclatement  des  gros  projectiles  sans 
plaie  exterieure.     Arch,  de  med.  et  pharm.  mil..  Par.,  1916-17.     Ixvi,  542. 

Guillain,  G.  et  Barre,  A.  Inversion  du  reflexe  achilleen  et  du  reflexe  medio- 
plantaire  dans  un  cas  de  lesion  du  nerf  sciatique  poplite  interne.  Presse 
med..  Par.,  1917,  v.  25,  p.  448. 

Guillain  et  Barre.  Hemorragie  meningee  consecutive  a  une  commotion  par 
eclatement  d'obus  sans  plaie  exterieure.  Meningite  a  pneumocoques  mor- 
telle  secondaire.  Bull,  et  mem.  soc.  med.  d'hop.  de  Par.,  1917,  v.  33,  pp. 
898-900. 

Guillain  and  Barre.  Les  troubles  sphincteriens  transitoires  dans  les  commotions 
par  eclatement  de  gros  projectiles  sans  plaies  exterieures.  Bull,  et  mem. 
soc.  med.  d'hop.  de  Par.,  1917,  v.  22,  pp.  1114-1118. 

Guillain  and  Barre.  Les  troubles  des  reactions  pupillaires  dans  les  commotions 
par  eclatement  de  gros  projectiles  sans  plaie  exterieure.  Bull.  Acad,  de 
med.,  Par.,  1917,  v.  78,  pp.  158-159. 

Guillain  et  Barre.  Troubles  pyramidaux  organiques  consecutifs  a  I'eclatement 
d'un  projectile  sans  plaie  exterieure.  Soc.  med.  d'hop.  Par.,  1916,  26 
mai. 

GuUlain  et  Barre.     Soc.  med.  d'h6p.     Par.,  1916,  21  Janvier. 

GuiUain  et  Barre.     Soc.  med.  d'hop.     Par.,  1916,  7  avril. 

Guillain  et  Barre.  Les  contractures  ischemiques.  Reunion  Med.  de  la  VI 
armee,  Jan.  12,  1916. 


934  BIBLIOGRAPHY 

Giiillain.  Les  nevrites  irradiantes  et  Ics  contractures  et  paralysies  traumatiques 
d'ordre  reflexe.     Soc.  Med.  des  Hopitaux,  May  26,  1916. 

Guillain  et  Barre.  Forme  clinique  de  la  nevrite  ciscendante.  Presse  med.  3  avril 
1916. 

GtiiUain  and  Barre.  (Lesions  with  external  wounds.)  Bull,  et  mem.  soc.  med. 
hop.  d  Par.,  1916,  v.  40,  p.  834. 

Guillain  and  Barre.  Deux  cas  d'astasie-abasie  avec  troubles  du  nerf  vestibulaire 
chez  les  syphilitiques  anciens.  Ann.  de  med.  Par.,  v.  3,   1916,  pp.  431-436. 

Guillain  and  Barre.  A  propos  d'un  cas  d'astasie-abasie  trepidante.  Presse 
med.,  Par.,  1916,  v.  24,  pp.  1 19-120. 

Guillain  and  Barre.  Apoplexie  tardive  consecutive  a  une  commotion  par 
eclatement  d'obus  sans  plaie  exterieure.      Ibid.,  1473-74. 

Guillain  et  Barre.  Hemiplegies  par  blessures  de  guerre.  Diagnostic  topo- 
graphique  du  siege  des  lesions.     Presse  med..  Par.,  1916,  v.  24,  pp.  121-122. 

Guillain  et  Barre.  Syndrome  d'avellis  bilateral,  manifestation  de  syphilis 
ner\'euse.     Presse  med.,  Par.,  1916,  v.  24,  p.  150. 

Guillain  et  Barre.  Deux  cas  d'hemiplegie  organique  consecutifs  a  la  deflagra- 
tion de  fortes  charges  d'explosifs,  sans  plaie  exterieure.  Paris  med.,  1916 
(Part.  Med.),  v.  21,  p.  420. 

Guillain  Barre  and  Strohl.  Etude  graphique  des  reflexes  tendineux  abolis  a 
I'examen  clinique  dans  un  cas  de  commotion  par  eclatement  d'obus  sans 
plaie  exterieure.     Bull,  et  mem.  Soc.  med.  d'hop.  de  Par.,   191 7,  3.  s,  xii, 

313-315-  ,  .  ,     ,. 

Gumpertz.     Beitrage  z.  Kenntniss  d.  Nervenschadigungen  des  Kriegs.  Aus  dem 

Kriegslazarett.     Berl.,  J.  Goldschmidt. 
Gunson,  E.  B.     Cardiac  symptoms  following  dysentery  among  soldiers.     Lancet, 

Lon.,  ii,  146. 
Gutzmann,  H.     Stimm-  und  Sprachstorungen  im  Kriege  und  ihre  Behandlung. 

Berl.  klin.  Wchnschr.,  1916,  v.  53,  pp.  154-158. 
Haas.     Sur  quelques  blessures  oculaires  occasionnees    par   les    engins   a    forte 

charge  d'explosif.     Presse  med..  Par.,  1916,  v.  24,  p.  52. 
Haberer,  H.  v.     Beitrag  zu  den  Schadelverletzungen  im  Kriege.     Wien.  klin. 

Wchnschr.,  1914,  v.  27,  pp.  1 590-1 593. 
Hadfield,  J.  A.     Influence  of  hypnotic  suggestion  on  inflammatory  conditions. 

Lancet,  Lond.,  1917,  v.  ii,  p.  678. 
Haddon,  John.     Shell-shock:   its  cause  and  proper  treatment  by  diet.      Domin. 

Med.  Mon.,  1918,  i,  33. 
Haddon,  J.     Shell  shock;   its  cause  and  proper  treatment  by  diet.     Med.  Press. 

Lond.,  1917,  n.  s.,  civ,  409-411. 
Hagedom.     Abnorme     Selbstbeschadigungen.     Deutsche     Zeitschr.     f.     Chir., 

Leipz.,  1916,  v.  137,  pp.  1-46. 
Hahn.     Kriegspsychosen.     Med.  Klin.  Berl.  u.  Wien.,  1915,  v.  3,  pp.  11 4-1 15. 
TTahn.     Uber   Kriegspsychosen.     Miinchen.f'med.,   Wchnschr.,   191 5,  v.  62^  p. 

268. 
Hakkebusch,  V.  M.     (What  is  caused  by  wind  contusion:    neurosis,  or  organic 

injury  of  the  nervous  system.)     Sovrem,  Psikhiat.,  Mosk.,  1915,  v.  9,  pp. 

389-405.  _  ...  .      , 

Hakkebusch,    V.    M.     (Nervous  diseases  in  connection  with  wmd  contusion.) 

Sovrem.  Psikhiat.,  Mosk.,  1916,  v.  10,  pp.  226-249. 
Halipre,  A.     Test  de  guerison  de  la  paralysie  radiale  (signe   des   flechisseurs) 

Rev.  neurol..  Par.,  1917,  v.  24,  pp.  87-89. 
Hamburger,  Franz.     Uber  simulierte  und  aggravierte  Bronchitis.     Mditararzt 

Wien.  med.  Wchnschr.,  191 5,  v.  49,  No.  35. 
Hamilton,  Allan  McLane.     Tests  for  the  perception"  efficiency  of  recruits.     Med. 

Rec,  N.  Y.,  1918,  v.  93,  pp.  285-286. 
Hamilton,  Allan  McLane.     Psychopathology  of  the   war.     Med.  Rec,  N.  Y., 

1915,  V.  87,  p.  no. 
Hammesfahr.     Vorstellung  zweier  Patienten  mit  Gehirnschiissen.     (Abstract.) 

Deutsche  med.  Wchnschr.,  191 5,  Berl.  u.  Leipz.,  v.  41,  p.  575. 
Hammond,  T.  E.     Involvement  of  the  external  and  internal  popliteal  nerves  in 

lesions  of  the  sciatic  ner^-e.     Brit.  Med.  Jour.,  1918,  i,  397. 
Harford,  C.  F.     Visual  neuroses  of  miners  in  their  relation  to  military  service. 

Brit.  M.  J.,  Lond.,  1916,  i,  pp.  340-342. 


BIBLIOGRAPHY  935 

Harris,  W.     Abnormal  median  and  ulnar  nerve-supply  in  the  hand.     Lancet, 

London,  1917,  ii,  710. 
Harris,  Wilfred.     Nerve  Injuries  and  Shock.  1915,  London,  Henry  Frowde. 
Harris,  Wilfred.     Shell  shock  without  visible  signs  of  injury.     Proc.  Roy.  Soc. 

Med.,  1915-16  (Sec.  Psychiat.),  pp.  33-34. 
Harrower,  H.  R.     Shell  shock  and  the  internal  secretions;    with  suggestions  as 

to  treatment.     Prescriber,  Edinb.,  1916,  x,  203-209. 
Harwood,  T.  E.     Nature  and  treatment  of  concussion.     Lancet,   Lond.,   1916, 

i,  P-  551- 
Harwood,  T.  E.     Shell  shock.     Lancet,  Lond.,  1916,  i,  698. 
Harwood,  T.  E.     Three  cases  illustrating  the  functional  consequences  of  head 

injuries.     Lancet,  Lond.,  1916,  ii,  v.  191,  p.  431. 
Harwood,  T.  E.     Functional  conditions  in  head  injuries.     J.  Roy.  Army  Med. 

Corps,  Lond.,  1917,  v.  28,  pp.  699-707. 
Harzbecker.    Ueber  die  Aetiologie  der  Granatkontusionsverletzungen.    Deutsche 

med.  Wchnschr.,  Berl.,  u.  Leipz.,  1914,  v.  40^,  p.  1985. 
Hauptmann,  A.      Kriegsneurosen   und  traumatische  Neurose.      Monatschr.  f. 

Psychiat.  u.  Neurol.,  Berl.,  1916,  v.  38,  pp.  20-32. 
Haxiry.     Un  dement  precoce  engage  volontaire.     Rev.  de  med.,  Par.,  1914-15, 

v.  24,  pp.  591-593- 
Haury.     Un  cas  de  "  folic  minime  "  chez  un  debile.     Presse  Med.,  Par.,  1915, 

v.  23,  p.  429. 
Haury.     Un  autre  deserteur  pathologique.     Presse  Med.,  191 5,  v.  23,  p.  429. 
Haury.     Les  retentissements  psycho-organiques   de   la   vie   de   guerre.     Presse 

Med.,  Par.,  I9i5,.v.  23,  pp.  458-459.^ 
Haury.     De   I'utilisation   des   indisciplines   en   temps   de   guerre.     Ann.    med. 

psychol..  Par.,  1916-17,  v.  7,  pp.  525-530. 
Hasrward,  E.     Beitrag  zur  Klinik  der  Schadelschiisse,  nach  den  Erfahrungen 

im  Heimatlazarett.     Berl.  klin.  Wchnschr.,  191 5,  v.  52,  pp.  1 186-1200;  and 

pp.  1212-1218. 
Hecht,  V.     Leitfaden  den  physikalisch-therapeutischer  Nachbehandlung  Kriegs- 

verwundeten.     W.  Braumiiller,  Wien.  u.  Leipz.,  1916.     Rev.  Deutsch.  med. 

Wchnschr.,  1916,  No.  39,  p.  1207. 
Heilig  and  Sick,  P.     Uber  Schussverletzungen  des  Gehirns.     Miinchen  med. 

Wchnschr.,  1915,  v.  621,  pp.  172-173. 
Heimanovich,   A.   I.     (Public  psychiatric  hospitals  and  the  war.)     Kharkov. 

M.  J.,  1915,  v.  20,  pp.  371-376. 
Heimanovich,  A.  I.     (Mental  diseases  of  war  time.)     Kharkov.  M.  J.,   1915, 

V.  20,  pp.  377-395- 
Heimanovich,  A.  I.     (Institutes  of  functional  reestablishment.)     Kharkov.  M.  J., 

1916,  V.  22,  pp.  243-252. 
Heitz,  Jean.     Cinq  cas  de  paraplegic  organique  consecutive  a  des  eclatements 

d'obus  sans  plaie  exterieure.     Paris  Med.   (Part.   Med.),   1915,  v.   17,  pp. 

78-85. 
Helys,   M.     The   reeducation   and   placement   of   war   cripples.     Am.   J.    Care 

Cripples,  N.  Y.,  1917,  v.  4,  pp.  168-178. 
Helys,   M.     Reeducation  and  placement  of  war  cripples.     Amer.   Jour.,   Care 

for  Crip.,  1917,  iv,  168. 
Henderson,  D.  K.     A  case  of  pathological  lying  occurring  in  a  soldier.     Rev. 

Neurol,  and  Psychiat.,  Edinb.,  1917,  v.  15,  pp.  223-232. 
Henderson,  Yandell  and  Seibert,  E.  G.     Organization  and  objects  of  the  Medical 

Research   Board,  Air  Service,   U.   S.   Army.     Jour.   A.   M.  A.,   1918,   Ixxi, 

1398. 
Hertz,  A.  F.     (See  also  Hurst.)     Paresis  and  involuntary  movements  following 

commotion  produced  by  the  bursting  of  a  large  shell.     Proc.   Roy.  Soc, 

Med.,  Lond.,  (sec.  Neurol.),  1914-15,  v.  8,  pp.  83-84. 
Hertz,  A.  F.     Nerves  and  the  War.     Guy's  Hosp.  Gaz.,  Lond.,   1915,  v.  29, 

pp.  169-173;  and  pp.  335-339- 
Hertz,  A.  F.     Concussion  Blindness.     Lancet,  1916,  1,  p.  15.  ^ 

Hertz,  A.  F.     Medical  diseases  of  the  war.     Lond.,  1917,  G.  Arnold,  pp.  151,8  . 
Hertz,  A.   F.   and  Ormond,  A.  W.     The  treatment   of  concussion  blmdness. 

Lancet,  Lond.,  1916,  i,  15-17- 


936 


BrBLIOGRAPHY 


Hesnard,  A.  Le  traitement  local  et  la  radiotherapie  locale  des  blessures  des  troncs 
nerveux.     Arch,  d'electric.  med.,  Bordeaux,  1916,  v.  26,  pp.  5-9. 

Hesnard,  A.  Note  sur  la  radiotherapie  des  blessures  des  troncs  nerveux.  Paris 
med.,  1916  (Par.  Med),  v.  19,  p.  302. 

Hesnard,  A.  Un  nouvel  element  de  la  reaction  de  degenerescence  —  I'hyper- 
excitabilite  galvanotonique  des  muscles.  Par.  med.,  191 7,  No.  46,  pp. 
410-415. 

Hesnard,  A.  Un  cas  d'hemiplegie  glosso-pharyngo-cervico-laryngee  par  syn- 
drome des  quatres  dernieres  paires  craniennes.  Arch,  de  med.  et  pharm. 
nav.,  Par.,  191 7,  v.  103,  pp.  370-377. 

Hesnard,  A.  Un  cas  de  psychose  post-onirique  chez  un  aliene  militaire.  Cadu- 
cee.  Par.,  1914,  xiv,  202. 

Hesse,  W.  Ueber  Spattetanus,  chronischen  Tetanus  und  Tetanusrezidiv. 
Deutsches  Archiv.  f.  klin.  Med.,  Leipz.,  191 7,  124,  p.  284. 

Hewat,  A.  Fergus.  Clinical  cases  from  Medical  Division,  Royal  Victoria  Hos- 
pital, Netley.     Edinb.  M.  J.,  1917,  v.  18,  pp.  210-215. 

Hezel.  Eine  im  Felde  vorkommende  Beschaftigungsneuritis.  Neurol.  Centralbl., 
37,  Nr.  15,  1918. 

Hill,  David  Spence.  Valid  uses  of  psychology  in^  the  rehabilitation  of  war 
victims.     Mental  Hygiene,  H,  October,  1918.' 

Hill,  L.  Death  from  high  explosives  without  wounds.  Brit.  M.  J.,  Lond.,  1917, 
V.  I,  p.  665. 

Hine,  M.  L.  The  recovery  of  fields  of  vision  in  concussion  injuries  of  the 
occipital  cortex.     Brit.  J.  Ophth.,  Lond.,  1918,  v.  2,  pp.  12-25. 

Hinsdale,  G.     Hydrotherapeutics  in  the  war.     N.  Y.  Med.  Jour.,   1917,  cvi, 

893- 
Hirschfeld,  Arthur.     Die  hydrotherapeutische  Behandlung  der  im  Kriege  erwor- 

bene  Neurasthenic  und  Hysteric.     Zerb.  f.  Phys.  u.  Diatet.,  Ther.,  Leipz., 

1915,  V.  19,  pp.  59-62. 
Hirtz,    E.    J.     Le    traitement    des    impotences  fonctionnelles  consecutives    aux 

blessures  de  guerre.     Presse  Med.,  Par.,  1915,  v.  23,  pp.  139-141. 
His,  W.     Ermiidungsherzen  im  Felde.     Med.  Klin.  Berl.  u.  Wien.,  1915,  v.  ii\ 

pp.  293-298. 
Hoch,   August.     Recommendations    for    the   observation   of    mental    disorders 

incident  to  the  War.     Psychiat.  Bull.  Utica,  191 7,  v.  2,  No.  3,  pp.  377-385. 
Hoche.     Krieg  und  Seelenleben,  191 5,  Speyer  and  Kaerner,  Freiburg. 
Hoche.      Die    Versorgung    der    funktionellen    Kriegsneurosen.      Miinch.    med. 

Wchnschr.,  1916,  v.  63,  p.  1782. 
Holland,  C.  T.     Two  years'  experience  of  war  radiography  in  a  base  hospital. 

Amer.  Jour.  Elec.  and  Radiol.,  191 7,  xxvi,  448.  ^ 

Hollande,  Lepe3rtre  et  Gate,  J.     Simulation  d'albuminurie  par  injection  intra- 

vesicale  d'ovalbumine.     Lyon  med.,  1916,  v.  125,  pp.  194-196. 
Hollande  et  Marchand.    A  propos  d'un  cas  de  maladie  de  Derkum.     Lyon  med., 

1917,  V.  126,  pp.  362-365. 
Holmes.  G.  and  Lister,  W.  T.     Disturbances  of  vision  from  cerebral  lesions, 

with  special  reference  to  the  cortical  representation  of  the  macula.     Proc. 

Roy.  Soc.  Med.,  Lend.,  1915-16,  v.  9  (sec.  Ophth.),  pp.  57-96. 
Holmes,  Gordon  and  Smith,  S.     Case  of  bilateral  motor  apraxia  with  disturb- 
ance of  visual  orientation.     Jr.  Roy.  Army  Med.  Corps,  Lond.,  1917,  i,  pp. 

78-91. 
Horder,  Thomas  J.     Cerebro-spmal  fever.  Lond.,  1915,  Henry  Frowde. 
Horn,  P.     Zur  Begutachtung  nervoser  Unfallfolgen.     Miinchen.  med.  Wchnschr., 

1915,  V.  62,  pp.  1745-48. 

Horn,  P.  Zur  Niitzbarmachung  erhaltener  und  wiedergewonnener  Arbeitskraft 
bei  Unfallsneurosen.  Aerztl.  sachverst.  Ztg.,  Berl.,  1915,  v.  21,  pp.  253-257; 
and  pp.  279-282. 

Horn,  P.  Uber  Sonnenstich  mit  organische  Symptomen.  Zentralbl.  Nervenk. 
u.  Psychiat.,  Coblenz.  u.  Leipz.,  1915,  v.  51,  No.  4.     Berl.  Klin,  Wchnschr. 

1916,  i.  No.  2,  p.  44. 

Horn,  P.     Zur  Aetiologie  und  klinischen  Stellung  der  Unfall-  und  Kriegsneurosen. 

Neurol.  Zentralbl.  Leipz.,  1917,  v.  36,  No.  3,  and  No.  7. 
Horsfall,  W.  N.     Malingering  in  the  services.     Med.  J.  Australia,  Sydney,  1916, 

iii.  54- 


BIBLIOGRAPHY  93  y 

Horsley,  Sir  Victor.     Address  on  gun-shot  wounds  of  the  head;   Lancet,  Lond., 

1915,  i,  pp.  359-362. 
Horstmaim.     Zur  traumatischen  Neurose.  Arztl.  Sachverst.  Ztg.,  Berl.,   1914, 

V.  22,  Nov.  5;  Rev.  Psychiat.  neurol.  Wchnschr.,  Halle,  a.  S.,  1914-15;  v.  16; 

P-  346. 
Horstmaim.      Traumatische    Neurose.      Arztl.    Centr.    Ztg.,    v.    27,    p.    53, 

also  p.  76. 
Hote.     Uber  Kriegsverletzen  des  Nervensystems.     Miinchen  med  Wchnschr., 

1914,  No.  45,  pp.  2219-2221;  and  pp.  2264-2266. 

Hotz.     Uber  Kriegsverletzungen  des  Nervensystems.     Zentralbl.  f.  Chir.,  Leipz., 

1915,  V.  421,  pp.  6-7. 

Hoven.     Les  maladies  mentales  et  la  guerre.     Presse  Med.,  191 7,  v.  53,  p.  559. 

How  to  Avoid  Damage  to  Auditory  Apparatus  by  Explosions.  Monde  med., 
1918,  v.  28,  pp.  61-63. 

Howard,  W.  L.     Psychology  of  War.     N.  Y.  M.  J.,  1915,  v.  loi,  p.  15. 

Howland,  G.  W.  Neurosis  in  returned  soldiers.  Med.  Fortnightly,  St.  Louis, 
1917,  V.  49,  pp.  97-100. 

Howland,  G.  W.  The  neuroses  of  returned  soldiers.  Am.  Med.,  Burlington, 
Vt.,  1917,  V.  23,  pp.  _3i3-3i9- 

Hrdlicka,  Ales.  Suggestions  relating  to  the  new  National  Army  by  the  An- 
thropology Committee  of  the  National  Research  Council.     (Wash.,    1917), 

P-4.  8°-  .  .  .  ... 

Hunt,  J.  R.     Exhaustion  pseudoparesis;    a  fatigue  syndrome  simulating  early 

paresis,  developing  under  intensive  military  training.     Jour.  A.  M.  A.,  Ixx,  11. 
Huntington,  P.  W.      The  present  and  proposed  Roentgenologic  Ser\dce  of  the 

United  States  Army.     Am.  J.  Roentgenol.,  Detroit,  191 7,  v.  4,  pp.  597-601. 
Hurst,  A.  F.     (See  also  Hertz.)     Nerves  and  the  war.     Guy's  Hosp.  Gaz.,  1915, 

V. 29,  pp.  169-173. 
Hurst,  A.  F.     Case  of  deaf-mutism  followed  by  partial  amnesia.     Guy's  Hosp. 

Gaz.,  Lond.,  1916,  v.  30,  p.  279;  also  pp.  410-412. 
Hurst,  A.  F.     Medical  diseases  of  the  war.  Lond.,  191 7,  Arnold,  p.  151,  8°. 
Hurst,  A.  F.     Observations  on  the   etiology  and  treatment   of  war  neuroses. 

Brit,  M.  J.,  Lond.,  1917,  ii,  pp.  409-414. 
Hurst,  A.  F.     (Nervous  Affections.) 

Hurst,  A.  F.     War  epilepsy.     Guy's  Hosp.  Gaz.,  Lond.,  191 7,  pp.  209-213. 
Hurst,  A.  F.     Classification  of  war  neuroses.     Guy's  Hosp.  Gaz.,  Lond.,  1917, 

xxi,  109.     Also:   Alienist  and  Neurol.,  St.  Louis,  1917,  xxxviii,  458. 
Hurst,  A.  F.     Etiology  and  treatment  of  war  neuroses.     Brit.  Med.  Jour.,  1917, 

ii,  409. 
Hurst,  A.  F.     Psycho-analysis   and  war  neuroses.     Guy's  Hosp.   Gaz.,   Lond., 

1917.  PP-  308-309.  ^ 

Hurst,  A.  F.     Syphilis  of  the  nervous  system  in  soldiers.     Guy  s  Hosp.  Gaz., 

Lond.,  1917,  pp.  365-368. 
Hurst,  A.  F.     Warfare    injuries   and  neuroses.     Proc.  Roy.  Soc.    Med.,  Lond., 

1917-18,  v.  10  (sec.  otol.),  pp.  115-118. 
Hurst,  Arthur  F.     Medical  diseases  of  the  war;   a  record  of  personal  experiences. 

Hospital,  Lon.,  1918,  Ixv,  9. 
Hurst,  A.  F.  and  Peters,  E.  A.     The  pathology,   diagnosis  and  treatment  of 

absolute  hysterical  deafness  in  soldiers.     Lancet,  Lond.,   I9i7i  v.   ii,   pp. 

517-519. 
Htirst,  A.  F.  and  Peters,  E.  A.     Pathology,  diagnosis,  and  treatment  of  absolute 

hysterical  deafness  in  soldiers.     Lancet,  Lon.,  19 17,  ii,  5I7- 
Hurst,  A.  F.  and  Peters,  E.  A.     Nerve-shattered  soldiers  and  their  treatment; 

Dr.  Lumsden's  excellent  scheme.     Hospital,  Lon.,  1917,  Ixii,  487. 
Hurst,  A.  F.  and  Syms,  J.  L.  M.     Rapid  cure  of  hysterical  symptoms  in  soldiers. 

Lancet,  Lon.,  1918,  ii,  139. 
Hutt,  C.  W.     Education  of  the  left  hand  of  disabled  sailors  and  soldiers.     Lancet, 

Lond.,  1917,  V.  I,  pp.  642-646. 
Hutt,  C.  W.     The  future  of  the  disabled  soldier.     Wm.  Wood,  19 1 7. 
Hypertension  des  nevroses  tachycardiques.     Rev.  gen.  de  clin.  et  de  therap.. 

Par.,  1916,  V.  30,  pp.  185-186. 
Hyslop,  T.  B.     The  psychology  of  warfare.     West  Lond.,  M.  J.,  1917.  v.  22, 

pp.  2-12, 


938  BIBLIOGRAPHY 

Imbert,  Leon.     Accidents  du  travail  et  blessures  de  guerre.     Une  nouvelle  loi. 

Presse  Med.,  Par.,  191 7,  v.  25,  pp.  591-592. 
Imbert,  Leon,  et  Real,  Pierre.     La  constriction  des  machoires,  par  blessure  de 

guerre.     Presse  med.,  Par.,  1916,  v.  24,  pp.  372-373. 
Imboden,  K.     Das  Neurosenproblem  im  Lichte  der  Kriegsneurologie.     Cor.  Bl. 

f.  Schweiz.  Aerzte.,  1917,  No.  34,  pp.  1098-1109. 
Isolation  and  Psychotherapy  for  soldiers  suflfering  from  functional  disturbances 

of  the  nervous  system.     Monde  med..  Par.,  1917,  v.  27,  pp.  113-115. 
Isserlin.     Kriegspsychiatrische   Erfahrungen.     Berlin,    klin.    Wchnschr.,    1916, 

v.  53,  p.  295. 
Jackson,  J.  A.     A  report  of  the  clinical  and  pathological  findings  in  a  case  of 

hystero-epilepsia  and  hystero-epileptoid.     Alienist  and  Neurol.,  St.  Louis, 
1915,  xxxvi,  231-235.^ 
Jacob,  O.     Tumeurs  consecutives  a  I'injection  d'huile  camphoree  preparee  avec 

de  I'huile  de  vaseline.     Compt.  rend.  Soc.  de  biol.,  Par.,  1917,  Ixxx,  371,  487. 
Jacobson,  L.     Krieg  und  Nervensystem.  Therap.  d.  Gegenw.,  Bed.,  1915,  v.  56, 

pp.  22-29. 
Jacobson,  L.     Krieg  und  Nervensystem.  Med.  Klin.,  Berl.  u.  Wien.,  1915,  v.  ii', 

p.  no. 
Jacquetty,  G.,  Bergonie,  J.     Le  travail  agricole  medicalement  present  et  sur- 

veille  comme  traitement  des  sequelles  de  blessures  de  guerre.     Arch,  d'elec. 

med.  et  physiotherap.,  Par.,  1917,  No.  148,  pp.  297-317. 
Jahrmarker.     IJeber  psychische  u.  nerv'ose  Storungen  bei  Kriegern.     Miinchen 

med.  Wchnschr.,  1915,  No.  33,  p.  11 18. 
Jarrett,  Mary  C.     The  Training  School  of  Psychiatric  Social  Work  at  Smith 

College.     V.  An  Emergency  Course  in  a  New  Branch  of  Social  Work.    Mental 

Hygiene,  II,  October,  191 8. 
JeanseLme  et  Huet.     Syndrome  jacksonien  de  nature  hysterotraumatique.     Rev. 

neurol..  Par.,  1914-15,  v.  22^,  pp.  723-726. 
Jeanselme  et  Huet.     Myotonie  acquise.     Rev.  neurol.,  Par.,   1916,  v.  29.  pp. 

414-418. 
Jelliffe,  Smith  Ely.     Nervous  and  mental  disturbances  of  influenza.     N.  Y.  Med. 

Jour.,  1918,  cviii,  725,  755,  807. 
Jelliflfe,  S.  E.     War  (The)  and  the  nervous  system.     I.  Peripheral  nerve  injuries. 

N.  Y.  Med.  Jour.,  1917,  cvi,  17. 
Jellinek,   S.     Zur   militararztlichen   Konstatierung  der   Epilepsie.   Wien.   klin. 

Wchnschr.,  1915,  v.  28,  pp.  1021-1025. 
Jellinek,   S.     Zur  militararztlichen  Konstatierung  der  Kriegsneurosen.     Wien. 

klin.  Wchnschr.,  191 6,  v.  29,  pp.  189-193. 
Jendrassik,  E.     Einige  Bemerkungen  zur  Kriegsneurose.     Neurol.   Centralbl., 

Leipz.,  1916,  V.  35,  No.  12. 
Jendrassik.  E.     Zur  Discussion  uber  die  Neurosenfrage.     Theorie  der  Hysteric 

und  der  Neurasthenic.     Neurol.  Centralbl.,  Leipz.,  1917,  36,  962. 
Jessop,   Walter,   H.   H.     Discussion  on  ophthalmic   injuries   in   warfare.     Tr. 

Ophth.  Soc.  V.  Kingdom,  Lond.,  1914-15,  v.  35,  pp.  1-68. 
Jessop,  Walter  H.     Shell  shock  without  visible  signs  of  injury.     Proc.   Roy. 

Soc.  Med.,  Lond.,  1915-16,  v.  9  (sec.  Psychiat.),  p.  36. 
Jobson,  T.  B.     Normal  gun-deafness.     Lancet,  Lon.,  191 7,  ii,  566. 
Johnstone,  E.  K.     Shell  Shock;   notes.     Mil.  Surg.,  1918,  xlii,  531. 
Jolly.     Uber  die  Dienstfahigkeit  und  Rentenfrage  bei  nervenkranken  Soldaten. 

Miinchen  med.  Wchnschr.,  1915,  v.  34,  pp.  1714-1719. 
Jolly,    Ph.     Arbeitstherapie    fiir    nervenkranken    Soldaten.      Deutsche    med. 

Wchnschr.,  1916,  v.  42,  p.  1514. 
Jolly,  P.     Uber  Kriegsneurosen.     Arch.  f.   Psychiat.,   Berl.,   1916,  v.   56,  pp. 

385-444. 
Joltrain,  E.     Camptocormie  et  paraplegie  consecutives  a  un  ensevelissement  par 

eclatement  d'obus.     Presse  med..  Par.,  1917,  v.  25,  pp.  194-195. 
Joltrain,  E.     Camptocormie  et  paraplegie  consecutives  k  un  ensevelissement  par 

eclatement  d'obus;    considerations  sur  Taction  due  choc  emotif.     Bull,  et 

mem.  soc.  med.  d'hop.  de  Par.,  1917,  v.  41,  pp.  431-436. 
Jones,  A.  B.  and  Llewelljm,  J.  L.     Malingering,  or  the  Simulation  of  Disease. 

Lond.,  1917,  Wm.  Heinemann. 
Jones,  I.  H.     Ear  (The)  and  aviation.     Jour.  M.  M.  A.,  1917,  Ixix,  1607. 


BIBLIOGRAPHY  939 

Jones,  Robert.     Notes  on  Military  Orthopedics.     Cassell  and  Co.,  1917. 
Jones,  Robert.     Orthopedic  surgery  in  its  relation  to  the  war.     Amer.  Jour., 

Care  for  Crip.,  1917,  vi,  119. 
Jones,  Robert.     The  Psychology  of  Fear  and  the  Effects  of  Panic  Fear  in  War 

Times.     J.  Ment.  Sc,  Lond.,  1917,  v.  63,  pp.  346-389. 
Jones,  Robert.     Notes  on  military  orthopaedics.     Lond.,   N.  Y.,  etc.,    1917, 

Cassell  and  Co.,  p.  132,  8°. 
Jones,  Robert.     The  orthopaedic  outlook  in   Military  Surgery.     Brit.   M.  J., 

Lond.,  1918,  i,  pp.  41-45. 
Jones,  W.  E.     Case  of  Shell  Shock.     M.  J.  Australia,  Sydney,  1916,  v.  i,  pp. 

203-204. 
Jones-Phillipson,  C.  E.      Special  Discussion  on  Warfare  Injuries  and  Neuroses. 

Proc.  Roy.  Soc.  Med.,  Lond.,  1917,  v.  10  (sec.  Otol.),  pp.  96-110. 
Jorger,    J.     Mobilmachung   als   krankheitsauslosendes   Trauma    bei   Dementia 

Praecox.  Cor.-Bl.  f.  Schweiz.,  Aerzte,  1914,  v.  44^,  No.  50,  pp.  1553-1570. 
Joseph,  E.     Einige  Erfahrungen  iiber  Schadelschiisse,  besonders  iiber  die  Bedeu- 

tung  des   Rontgenbildes  fiir  die  Schadelchirurgie.     Munch.   Med.   Woch., 

1915,  Ixii,  1 197. 

Joubert,  Camille.  Note  sur  un  cas  de  paraplegic  organique  consecutive  a  la 
deflagration  d'un  obus  de  gros  calibre  sans  plaie  exterieure.  Paris  med., 
1915  (Part,  Med.),  v.  17,  pp.  444-446. 

Jourdan.  Un  cas  d'oedeme  provoque  du  membre  inferieur.     Montpel.   med., 

1916,  xxxix,  446-449. 

Jourdan  and  Sicard.  Etude  macroscopique  et  microscopique  des  lesions  des 
nerfs  par  blessure  de  guerre.     Presse  med.  July  29,  1915. 

Jourdran,  Maurice-Louise-Marie.  Crises  nerveuses  chez  les  blesses  de  guerre 
craniocerebraux.  (Epilepsie  generalisee,  hysterie,  hystero-epilepsie).  Bor- 
deaux, 1917,  88  pp.,  8,  +  No.  I. 

Jourdran  et  Marchand,  L.     De  la  rage  chez  I'homme.     Presse  Med.,  Par.,  1917, 

V.   25,    pp.    371-373-  ^  ,  r     T^  ,   • 

Juliusburger,  O.     Zur  Kenntnis  der  Knegsneurosen.     Monatschr.  f.  Psychiat.  u. 

Neurol.,  Berl.,  1915,  v.  38,  pp.  305-318. 
Jumentie.     Discussion  de  la  conduite  a  tenir  vis-avis  des  blessures  du  crane  — 

par  F.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  p.  463. 
Jiunentie.      Contraction  neuro-musculaire  et  reflexes  tendineux  dans  certains 

etats   d'impotence    dits    fonctionnels   et    a    caracteres    psychonevrosiques. 

Etude  par  la  methode  graphique.     Rev.  neurol..  Par.,  1916,  No.  6,  p.  960. 
Jumentie.     Deux  cas  d'hemiatrophie  linguale  associee  a  d'autres  paralysies  des 

nerfs  craniens  et  rachidiens  chez  des  commotionnes.     Montpel.  med.,  1917, 

xxxix,  1 006-1 009. 
Juquelier,  P.     Un  cas  complexe  d'appreciation  de  la  responsibilite  penale  chez 

un  epileptique.     J.  de  med.^de  Par.,  1917,  v.  36,  pp.  47-48. 
Juquelier,  P.,  et  Quellien,  P.     Epilepsie  larvee  par  traumatisme  de  guerre  (com- 
motion cerebrale).     Ann.  med.  psychol.  Par.,  191 7,  v.  73,  pp.  536-546- 
Kafka,  V.     Fortschritte  der  fiir  die  Psychiatrie  wichtigen  biologischen,  insbe- 

sondere    serologischen    Forschungsgebiete.     Jahresb.    f.    Arztl.    Fortbild., 

Munchen,  1915,  v.  5,  pp.  51-54-  ,  x     ,,       , 

Kafka.     Schreckneurose.     (Arztl.  Verem  Hamburg,  26,  Jan.,  1915-)     Munchen. 

med.  Wchnschr.,  1915,  v.  62,  p.  198. 
Kahne,    Max.     Uber   die    Anwendung   der   physikalischen    Heilmethoden    bei 

Kriegskrankheiten.     Wien.  med.  Wchnschr.,  1914,  v.  64,  pp.  540-547. 
Kahne,  Max.     Vorschlage  zur  Organisation  der  spezialarztlichen  Dienstleistung 

in  Kriegszeiten.     Wien.  klin   Wchnschr.,  1914,  ii,  pp.  1262-1263. 
Kahne,  Max.     Uber  Hyperthyreoidismus  vom  Standpunkte  der  Kriegsmedizin. 

Wien.  klin.  Wchnschr.,  1915,  v.  281,  pp.  148-153. 
Kalhof.     Operierte   Schadelschusse.     Ther.  Monatschr.,  Berl.,  1915,  v.  29,  pp. 

450-453. 
Kalt.     Rapport  sur  les  maladies  simulees  et  les  maladies  provoquees.     Clm. 

Ophth.  Par.,  1916,  v.  21,  pp.  500-504.  . 

Karplus,   I.   P.     Ueber    Erkrankungen   nach   Granatexplosionen.     Wien.    klm. 

Wchnschr.,  1915,  v.  28,  pp.  145-148.  ,    c  u 

Karplus,  I.  P.     Ueber  eine  ungewohnliche  zerebrale  Erkrankung  nach  bchrap- 

nellverletzung.    Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  456-462. 


940  BIBLIOGRAPHY 

Kashtshenko,  P.  P.  (Statistics  of  the  movement  of  insane  soldiers,  according 
to  data  obtained  by  an  inquiry.)  Psikhiat.,  Gaz.,  Petrogr.,  1915,  v.  2,  pp. 
199-203. 

Kashtshenko,  P.  P.  (History  of  development  of  measures  for  the  care  of  insane 
soldiers  and  those  participating  in  military  events.)  Psikhiat.  Gaz.,  Petrogr., 
1916,  V.  3,  pp.  151-156. 

Kashtshenko,  P.  P.  (A  propos  of  M.  B.  Krol's  article,  "  Statistics  of  the  move- 
ment of  insane  soldiers,  etc.")      Ibid.,  1916,  iii,  22,  43.  _ 

Kashtshenko,  P.  P.  (Certain  data  concerning  insane  warriors,  prepared  by  the 
combined  Statistico-Psychiatrical  Bureau  of  the  Unions  of  Zemstvos  and 
Municipalities.)     Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  353-377- 

Kastan,  Max.  Forensisch-psychiatrische  Beobachtungen  an  Angenhorigendes 
Feldheeres.  Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41,  pp. 
734-737. 

Kastan,  Max.  Die  strafbaren  Handlungen  psychischkranker  Angehoriger  des 
Feldheeres.     Archiv.  f.  Psychiat.,  Berl.,  1916,  pp.  573-631. 

Kaufmann,  Fritz.  Die  planmassige  Heilung  komplizierter  psychogener  Bewe- 
gungsstorungen  bei  Soldaten  in  einer  Sitzung.       Miinch.  med.  Wchnschr., 

1 91 6,  V.  631,  pp.  802-804. 

Keiper,  G.  F.     Pretended  blindness  and  deafness  and  their  detection.     J.  Indiana 

M.  Ass.,  Fort  Wayne,  1917,  x,  422-426. 
Keith,   John  R.      Vasodilators   in   the   treatment   of   hysterical   aphonia.    Brit. 

M.  J.,  Lond.,  1915,  i,  p.  847. 
Kennedy,  F.     Clinical  observations  on  shell  shock.     Med.  Rec,  N.  Y.,  1916, 

V.  89,  p.  388. 
Kennedy,  Foster.     Nature  of  nervousness  in  soldiers.     Jour.  A.  M.  A.,  1918,  Ixxi, 

17- 
Kenyon,  E.  L.     The  stammerer  and  army  service.     J.  Am.  M.  Ass.,  Chicago, 

191 7,  V.  69,  p.  664. 

Khoroshko,  V.  K.     (Psychiatric  impressions  and  observations  in  the  regions  of 

the  active  army.)     Psikhiat.  Gaz.,  Petrogr.,  1915,  v.  2,  pp.  377-383. 
Khoroshko,  V.  K.      (Mental  disturbances  following  physical  and  mental  shock 

in  the   war;    traumatic   psychoses   in  the  active  army.)     Psikhiat.   Gaz., 

Petrogr.,  1916,  v.  3,  pp.  3-10. 
Khoroshko,  V.  K.     (Organization  of  aid  to  warriors  with  wounded  or  diseased 

nervous  system.)     Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  398-401. 
Kidner,  E.  B.     The  vocational  reeducation  of  the  disabled  soldier.     Am.  Med., 

Burlington,  Vt.,  191 7,  v.  2t„  pp.  405-408. 
Kinberg,  O.     (Psychoneuroses  in  soldiers  at  the  front.)     Hygiea,  Stockholm, 

1916,  V.  78,  pp.  97-126. 
Kindlmann.     Entlarvung    von   Taubheit    und   Schwerhorigkeit    Simulierenden. 

Wien.  klin.  Wchnschr.,  1915,  v.  28,  p.  1069. 
Earmsze,  M.     Geistesschwache  als  Helden.     Ztschr.  f.  d.  Behndl.,  Schwachsinn. 

u.  Epilept.,  Dresd.,  1915,  No.  9,  pp.  134-141. 
Kleist.     Schreckpsychosen.     Neurol.  Centralbl.,  37,  Nr.  16,  1918. 
Kluge,  O.     Hysterische  Seh-  und  Hrostorungen  bei  Soldaten;    (Inaug.  Dissert. 

Berl.,  1914).     Rev.  Neurol.  Centralbl.,  Leipz.,  191 5,  v.  34,  p.  735. 
Knapp,  Paul.     Kriegschadigungen  der  Sehorgane.     Cor.-Bl.  f.  Schweizer  Aerztl., 

1916,  Nr.  38,  pp.  1185-1201. 
Koblylinsky,  M.     La  psichiatria  e  la  guerra.     Quaderni  di  psichiat.,  Genova, 

1914,  i,  pp.  337-341- 
Kofier.     Fall   von   hysterischer  Gehstorung  nach  Schussverletzung  des  Unter- 

schenkels.     Wien.  med.  Wchnschr.,  1915,  No.  i,  p.  39. 
Koixindjy,  P.     Le  massage  methodique  chez  les  blesses  de  guerre.     Presse  med., 

Par.,  1914,  V.  22,  pp.  610-61 1. 
Kouindjy,  P.     La  reeducation  chez  les  blesses  de  la  guerre  et  le  role  de  la  sup- 

pleance.     Bull.  Acad,  de  med..  Par.,  1915,  3  s.,  v.  74,  pp.  105-108. 
Kouindjy,  P.     La  reeducation  des  mouvements  chez  les  blesses  de  guerre.     Paris 

med.,  1915-16,  V.  17,  pp.  298-302. 
Kouindjy,  P.     La  kinesitherapie  de  guerre.     Paris,  19 16,  A.  Maloine  and  Fils. 
ELrebs.     Ohrbcschadigungen  im  Felde.     Miinch.   med    Wchnschr.,  1915,  v.  62, 

PP-  347-3^9- 
Kreuser,  D.    Zur  Frage  der  Knegspsychosen.     Allg.  Ztschr.  Psychiat.,  74,  191 8. 


BIBLIOGRAPHY  94I 

Krieg  und  Wahnsinn.     Psychiat.  Neurol.  Wchnschr.,  Halle  a.  S.,  1914-15,  v.  16, 

p.  298. 
Elrol,  M.  B.     (Statistics  of  the  movement  of  insane  soldiers;    Apropos  of  P.  B. 

Kashtshenko's  article :   "  Statistics  of  the  movement  of  insane  soldiers,  etc.,") 

Psikhiat.  Gaz.,  Petrogr.,  1915,  v.  2,  pp.  287-291. 
Kriiche,    A.     Zur    medico-mechanischen    Nachbehandlung    der    verwundeten 

Krieger.     Aerztl.  Centralbl.  Ztg.,  Wien.,  1915,  v.  27,  pp.  43-45. 
Kruckmann,    E.     Ueber    Kriegsblindenfursorge.     Deutsche    med.    Wchnschr., 

Leipz.  u.  Berl.,  1915,  v.  41,  p.  725;   p.  763;  p.  788. 
Kriill.     M.    Die  Strafrechtliche   Begutachtung  der  Soldaten  im  Felde.     Berl. 

klin.  Wchnschr.,  Nr.  24,  1918. 
Kuehn,  A.     Ueber  functionelle  Erkrankungen  des  Nervensystems  bei  Kriegs- 

teilnehmern.     Ztschr.  f.  Med.  Beamte,  Berl.,  1917,  30,  497. 
Laborderie,  J.     La  mecanotherapie  dans  les  formations  sanitaires.     Rev.  gen. 

de  clin.  et  de  therap..  Par.,  1915,  v.  29,  p.  327. 
Lagrange.     Des  desordres  oculaires  mediats  ou  indirects  par  les  armes  k  feu. 

Bull.  Acad,  de  med..  Par.,  1915,  v.  73,  pp.  591-601. 
Lagrange,  Felix.     Les  fractures  de  I'orbite.     Paris,  191 7,  Masson  and  Cie. 
Lahy,  J.  M.     Sur  la  psycho-physiologie  du  soldat  mitrailleur.     Compt.  rend. 

Acad.  d.  sc,  Par.,  1916,  v,  163,  pp.  33-35. 
Laignel-Lavastine.     Diagnosis   and   treatment    of   war  psychoneuroses,  espec- 
ially with  reference  to  cases  of    convulsions    and    asthenia.      War^  Med., 

1918,  ii,  44. 
Laignel-Lavastine.     Rapport  sur  le  centre  neurologique  de  la  I'*  region.      Rev. 

neurol.,  Par.,  1914-15,  v.  22^,  p.  1165. 
Laignel-Lavastine.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures 

du  crcine  —  par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  472. 
Laignel-Lavastine.     Sur  les  accidents  nerveux  determines  par  la  deflagration  de 

fortes  charges  d'explosifs.     Rev.  neurol.  Par.,  1916,  v.  29,  pp.  595-596. 
Laignel-Lavastine.     Sur  la  relative  frequence  des  cas  de  peur  invincible,  chez  les 

combattants.     Ann.  med.-psychol..  Par.,  1917,  v.  73,  pp.  380-384. 
Laignel-Lavastine.     Centre  des  psychonevroses  du  gouvernement  militairede 

Paris.     Rev.  neurol.,  Par.,  1916,  xxiii,  649-656. 
Laignel-Lavastine    et   Ballet,   V.     "  Pseudo-ptosis    hysterique "    avec   synergie 

fonctionnelle  oculo-palpebrale.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  179-181. 
Laignel-Lavastine  et  Ballet,  Victor.     Manierisme  pueril  post-confusionnel.     Ann. 

med.-psychol..  Par.,  1917,  v.  23,  pp.  232-240. 
Laignel-Lavastine   et  Courbon,  Paul.     Camptodactylie,  causalgie  et  inversion 

du  reflexe  tricipital  par  lesion  de  la  VII  paire  cervicle.     Rev.  neurol..  Par., 

1916,  V.  29,  pp.  927-932. 
Laignel-Lavastine  et  Courbon,  Paul.     Amaurose  par  eclatement  d'obus  avec 

meningite    syphilitiquc.     (Presentation    de    malade.)     Rev.    neurol..    Par., 

1916,  V.  24,  pp.  402-405. 
Laignel-Lavastine  et  Courbon,  Paul.     Les  deviations  de  la  colonne   vertebrale: 

le  Campto-Rachis.    Rev.  gen.  de  pathol.  de  guerre,  Par.,  1916,  No.  i,  pp. 

1-18. 
Laignel-Lavastine  et  Courbon,  Paul.     Les  troubles  de  la  marche  consecutives 

aux  emotions  et  commotions  de  la  guerre.     Paris  med.,  1916,  v.  21,  pp. 

194-203. 
Laignel-Lavastine  et  Courbon,  P.     Stereotypies  de  la  marche,  de  I'attitude  et 

■je  la  mimique  avec  representation  mentale  professionnelle  de  I'ouie  con- 
secutives aux  emotions  du  champ  de  bataille.     Ann.  med.-psychol.,  Par., 

1916-17,  V.  7,  pp.  498-505-  ,       .      ,     .        ,  ,  ,      r       .•         1 

Laignel-Lavastine  et  Coxurbon,  P.     De  la  simulation  des  troubles  fonctionnels 

du  systeme  nerveux  par  les  debiles  mentaux.     Ann,  med.-psychol..  Par., 

1916-17,  v.  7,  pp.  512-519. 
Laignel-Lavastine  et  Courbon,  P.     Trois  dysbasies  differentes  consecutives  a 

des  blessures  de  la  region  du  tenseur  du  fascia  lata  (Essai  de  physiologic 

pathologique  neuro-musculaire).     Rev.  neurol.,  Par.,  1917,  v.  24,  pp.  221- 

224.  1  •      J 

Laignel-Lavastine  et  Courbon,  P.  Syndrome  sympathique  cervical  oculaire  de 
paralysie  avec  hemianidrose  cervico-faciale  et  aphonic  hysterique  par  blessure 
cervicale  droite.     Rev.  neurol.,  Par.,  1917,  v.  24,  p.  509. 


942  BIBLIOGRAPHY 

Laignel-Lavastine  et  Courbon,  P.     Feminisme  post-ourlien  (microrchidie  et  gyne- 
comastie  consecutives  k  une  orchite  double).     Presse  med.,  Par.,  1917,  v. 

25,  P-  492. 
Laignel-Lavastine  et  Coiirbon,  P.     Essai  sur  I'insincerite  chez  les  accidentes  de 

la  guerre,     Paris  med.,  1917,  No.  27,  pp.  14-19. 
Laignel-Lavastine  et  Courbon,  P.     Prophylaxie  et  traitement  de  I'insincerite 

chez  les  accidentes  de  la  guerre.     Paris  med.,  1917,  No.  46,  pp.  407-410. 
Laignel-Lavastine  et  Cotirbon,  P.     Syndrome  psychasthenique  consecutif  aux 

emotions  de  guerre.     Ann.  med.-psychol.,  Par.,  1917,  v.  73,  pp.  391-403. 
Laignel-Lavastine  et  Courbon,  P.     Etats  seconds  cataleptiformes  post-confu- 

sionnels  par  emotion-choc  de  guerre.     Ann,  med.-psychol.,  Par.,  1917,  v.  73, 

pp.  411-422. 
Laignel-Lavastine  et  Courbon,  P.     Psychastheme  acquise.     Ann.  med.-p)sychol. 

Par.,  191 7,  V.  73,  pp.  582-588. 
Laignel-Lavastine  et  Fay,  H.  M.     Psychogenese  d'une  crise  hysterique.     Ann. 

med.-psychol..  Par.,  191 7,  v.  73,  pp.  422-425. 
Landau.     Le  principe  de  I'isolement  psychique  dans  le  traitement  des  troubles 

nerveux  fonctionnels.     Presse  med..  Par.,  1916,  v.  25,  p.  312. 
Landau.     Le  principe  de  I'isolement  psychique  dans  le  traitement  des  "  troubles 

nerveux  fonctionnels  "  de  guerre.     Bull.  Acad,  de  med.  de  Par.,  20  juin 

1917,  V.  3',  p.  236,  No.  23.  _ 

Lande,  P.  et  Marguery,  F.     Contribution  k  I'etude  experim.entale  de  I'ictere 

simule  picrique.     J.  de  med.  de  Bordeaux,  1917,  v.  88,  pp.  277-280. 
Landolt,   Marc.     Les  troubles  de  la  vision  nocturne  chez  les  soldats.     Arch. 

d'ophth..  Par.,  1917,  v.  35,  pp.  580-605. 
Lannois   (avec   M.   Chavanne).     Des  surdites  totales   par  eclatement   d'obus. 

Bull.  Acad,  de  Med.,  Par.,  1915,  v.  73,  pp.  105-108. 
Lannois  et  Chavanne.     Des  surdites  totales  par  eclatement  d'obus.     J.  med. 

et  de  chir.,  1915,  v.  86. 
Lannois  et  Chavarme,  F.     Le  pronostic  des  surdites  de  guerre  (d'apres  1000  cas). 

Rev.  Paris,  med.  (Part,  med.),  v.  19,  p.  36. 
Lannois,   M.   et  Chavanne,  F.     Le  pronostic  des  surdites  de  guerre   (d'apres 

1000  cas.).     Lyon  med.,  1916,  v.  125,  pp.  35-40. 
Lannois  et  Chavanne,  F.     La  surdite  de  guerre  bilaterale  totale.     Reeducation 

auditive  ou  lecture  sur  les  levres?     Lyon  med.,  19 16,  v.  125,  pp.  479-487. 
Lannois  et  Chavanne.     Reeducation  auditive  ou  lecture  sur  les  levres  dans  la 

surdite  bilatorale  totale.     J.  d.  med.  Par.,  1917,  pp.  I14-I15. 
Laquerriere,    A.     Notes   sur    1 'electro-diagnostic   de   guerre.     J.    de    radiol.    et 

d'electrol.,  Par.,  1916,  v.  2,  pp.  19-30. 
Laquerriere,  A.     L'electricite  dans  la  reeducation  des  troubles  nevropathiques 

des  blesses  de  guerre.     J.  de  radiol.  et  d'electrol..  Par.,  1917,  v.  2,  pp.  459- 

467.^ 
Laquerriere   et   Peyre.     La   physiotherapie   preventive   dans    les   blessures   de 

guerre.     J.  de  med.  et  de  chir.,  1915,  v.  86.     June. 
Lai'at    et   Billiard.     L'electrotherapie    pendant    la   reeducation    professionnelle. 

Arch,  d'elect.  med.  et  de  physiotherap.,  Par.,  1917,  No.  418,  pp.  335-336. 
Laret,   J.   et  Billiard,   A.     filectricite  medicale  et  reeducation  professionnelle. 

Paris  med.,  191 7,  No.  43,  pp.  344-347. 
Larat,    J.    et    Lehmann,    P.     Traitement    electrique    simplifie    des    accidents 

nerveux  consecutifs  aux  blessures  de  guerre.     Presse  med.,  Par.,  1915,  v. 

23.  PP-  35-37; 
Lattes,  L.     I  semi-alienati  in  medicina  legale  militare  e  il  concetto  di  pericolo- 

sita.     Riv.  di  med.  leg.,  Pisa,  1917,  vii,  iv,  49. 
Laudenheimer.      Die     Anamnese     der     sogenannten      Kriegspsychoneurosen. 

Miinchen.  med.  Wchnschr.,  1915,  v.  62,  pp.  1302-1304. 
Latirent,  O.     Accidents  nerveux  produits  k  distance  par  les  projectiles  de  guerre. 

Compt.  rend.  acad.  d.  sc,  Par.,  1914,  v.  158,  pp.  1211-1213. 
Lautier-Jean,  H.  M.  A.     Contribution  a  I'etude  des  maladies  mentales  dans 

I'armee.      Peut-on    utiliser    les    imbeciles?      Theses    de    Paris,    1915-1916, 

y.  8. 
Lautier,  J.     Medecine  mentale  de  guerre.     Presse  med.,  1917,  v.  25,  p.  492. 
Lautier.  J.     Un  cas  de  delire  mystique  chez  un  Musulman.     Ann.  med.-psychol., 

Par.,  1917,  V.  73,  pp.  404-411. 


BIBLIOGRAPHY  943 

Lattes,  Leone,  e  Goria,  Carlo.     Alcune  considerazioni  attorno  alli  psiconeurosi 

d'origine  bellica.     Arch,  di  antrop.  crim.  (etc.),  Torino,   19 17,  v.  38,  pp. 

97-117. 
Laval,  E.     Des  abces  par  injection  de  petrole.     Bull,  et  mem.  Soc.  de  chir.  de 

Par.,  1915,  n.  s.,  xli,  2378-2382.     Also:   Bull,  med..  Par.,  1916,  xxx,  94-96. 
Lawson,  A.     Blinded  sailors  and  soldiers;   remarks  on  the  training  at  St.  Dun- 

stan's.     Lancet,  Lond.,  1917,  v.  i,  p.  223. 
Lawson,  A.     How  blinded  soldiers  are  cared  for.     Hospital,  Lon.,  Ixi,  319. 
Lawson,  A.     Making  the  unfit  into  serviceable  recruits.     Hospital,  Lon.,  lix, 

390. 
Lebar.     Sur  un  cas  de  canitie  rapide.     Bull,  et  mem.  soc.  med.  d'hop.  de  Par., 

191 5.  V.  39,  pp.  439-443- 

Lebar.     Sur  I'oedeme  hysterique.     Bull,  et  mem.  soc.  med.  d'hSp.  de  Par.,  1915, 

V.  39,  PP-  757-760. 
L'ecole  de  reeducation  professionelle  et  les  oeuvres  d'assistance  pour  les  mutiles 

k  Bordeaux.     J.  de  med.  de  Bordeaux,  1915-1916,  v.  45,  pp.  139-141. 
LeClerc  et  Tixier.     Un  cas  de  paralysie  totale  du  plexus  brachial  droit  compliquee 

de  paraplegie  spasmodique  produite  par  le  meme-projectile.     Lyon  med., 

1916,  v.  125,  pp.  196-199. 

Le  Damany,  P.     La  paralysie  du  facial  superieur  dans  I'hemiplegie  cerebrale. 

Presse  med.  Par.,  1917,  v.  25,  pp.  1-3. 
Le   Dantec.     Reeducation  et   auto-reeducation  des  blesses  de  guerre.     J.   de 

med.  de  Bordeaux,  191 7,  v.  88,  pp.  219-224. 
Ledoux-Lebard,  R.,  Chabaneix,  Dessane.     L'importance  des  variations  du  sque- 

lette  dans  le  diagnostic  radiologique  des  blessures  de  guerre.     J.  de  radiol.  et 

electrol.,  1914-15,  v.  i,  pp.  689-693. 
Lee,  John  R.     A  case  of  gunshot  wound  of  the  head  with  a  piece  of  shrapnel  in 

the  brain;  value  of  the  use  of  an  electric  magnet  and  x-ray  screen  for  removal. 

J.  Roy.  Army  Med.  Corps,  London,  1916,  v.  26,  pp.  105-106. 
Leeson,   C.     The  war  and    juvenile  delinquency.      Pub.  for  Howard  Ass.  of 

Lond.,  by  P.  S.  King  and  Son,  Ltd.,  1917.     (i  s.  net.) 
Le  Fur,  Rene.     Abces  du  cerveau  (lobe  temporal) ,  consecutif  k  une  plale  par  eclat 

d'obns  en  avant  de  I'oreille.     Paris  Chirur.,  1916,  v.  8,  pp.  276-278. 
Legros.     L'electrotherapie  de  guerre.     Paris,  1916,  A.  Maloine  et  fils. 
Legueu,  F.     Battlefield  urology;    urinary  and  vesical  psychoses  in  the  fighting 

line.     Med.  Press  and  Circ,  Lond.,  191 5,  n.  s.,  v.  100,  pp.  11. 
Legueu,  F.     De  I'incontinence  d 'urine  et  des  psychoses  vesicales  chez  les  com- 

battants.     Bull.  Acad,  de  Med.,  Par.,  1915,  v.  73,  pp.  314-315- 
Leitner,  P.     Wien.  klin.  Wchnschr.,  1917,  30,  1327-28. 
Lelong,  Marcel.     Quelques  formes  de  la  fatigue  k  I'avant.     Paris  med.,  1917, 

No.  3,  pp.  66-68. 
Lemon,  Felix.     Functional  cases.     Discussion.     Proc.  Roy.  Soc.  Med.,  Lond., 

1914-15  (Sect.  Laryncol.),  v.  8,  p.  117. 
Lenoir,  R.     Contribution  a  I'etude  des  phenomenes  psychologiques  et  physiolo- 

giques  observes  pendant  la  narcose.     Rev.  neurol.,  1914-15,  v.  2211,  pp.  1310. 
Lents,  A.     (The  war  and  hysterical  stigmata.)     Psikhiat.  Gaz.,  Petrogr.,  1915, 

V.   2,    pp.    152-155-  .  ,  ,    .  ^  t.-  •  /  N 

Lenz.     La  guerre  et  les  stigmates  hystenques.     Gazette  psychiatnque  (russe), 

1915- 
Lepine,  Jean.     Troubles  mentaux  de  guerre.     Collection  Horizon,  Masson  et 

Cie,  Paris,  19 18.  -        »j 

Lepine,  Jean.     Commotions  nerveuses  k  la  suite  d'explosions.     Rev.  Pans  med. 

(Part,  med.),  1916,  v.  21,  p.  67. 
Lepine,  J.     Discussion  de  la  conduite  k  tenir  vis-i-vis  des  blessures  du  crine  — 

par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  p.  473. 
Lepine,  J.     Centre  de  psychiatrie  de  la  14^  region.     (Lyon).     Rev.  neurol..  Par., 

19 16,  xxiii,  698-701. 
Lepine,  J.     La  commotion  des  centres  nerveux  par  explosion.     Bull.  acad.  de 

med.  de  Par.,  1916,  v.  75,  pp.  9-11.  .  ..  <- 

Lepine  J.     La  commotion  des  centres  nerveux  par  explosion.     Lyon  med.,  1916, 

v.  125,  pp.  181-182. 
Lepine,   J.     Reformes,  incapacities,  gratifications  dans  les  psychoses,      ibid., 

803-809. 


944  BIBLIOGRAPHY 

Lepine  J.     Troubles  mentaux  de  guerre.     Les  solutions  militaires.     Presse  med., 

Par.,  191 7,  V.  25,  pp.  659-663. 
Leplat,  Georges.     Note  sur  un  cas  de  troubles  oculaires  produits  k  distance  par 

une  explosion.     Arch.  med.  Beiges,  Brux.,  1917,  v.  47,  pp.  412-415. 
Leppmann.     Psychiatrische  und   nerv^enarztliche  Sachverstandigentatigkeit  im 

Pvrieg.  Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41,  p.  209. 
Lerda,  G.     Contribute  alia  conoscenza  delle  suppurazioni  da  benzina.     Gior. 

di  med.  mil.,  Roma,  1916,  Ixiv,  586^-590. 
Lereboullet.     Spasmes  consecutifs  a  la  paralysie  faciale.     Rev.  gen.  de  clin.  et 

de  therap..  Par.,  1917,  v.  31,  p.  294. 
Lereboullet,  P.  et  Mouzon,  J.     Hallucinations  de  la  vue  et  crises  jacksoniennes 

dans  un  cas  de  lesion  du  cortex  visuel.     Paris   med.,   1917,  No.  27,  pp. 

19-23- 
Leredu.     Reponse  du  ministre  de  la  guerre  au  sujet  de   I'envoi  en  convales- 
cence des  alienes  militaires  gueris  et  fortunes  en  cas  de  refus  par  leur  famille 

de  les  recevoir.     Soc.  de  med.  Leg.  de  France,  Bull.  Par.,  1916,  v.  13,  pp. 

X79-180. 
Leri,  Andre.     Commotions  et  Emotions  de  guerre.     Collection  Horizon,  Masson 

et  Cie,  Paris,  1917. 
Leri,  Andre.     Sur  les  pseudo-commotions  ou  contusions  medullaires  d'origine 

fonctionelle.     Rev.  neurol.,  Par.,  1914-15,  v.  22-,  pp.  433-436. 
Leri,  A.     L'electrisation  directe  des  troncs  nerveux  au  cours  des  interventions 

pour  blessures  des  nervs  ses  donnees  pratiques.      Paris  med.,  1915  (Part. 

Med.),  v.  17,  pp.  134-138. 
Leri,  A.     Hemorragie  de  la  couche  optique  par  commotion  pure.     Hemiplegie 

avec  hemianesthesie  a  type   cerebral.      Soc.    med.   d'hop..    Par.,   26   mai, 

1916. 
Leri,    A.      Hemorragie    de    I'epicone    medullaire    par    commotion    (eclatement 

d'obus  k  proximite).     Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  133-135. 
Leri,  A.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  crane  —  par 

P.  Marie.     Rev.  neurol.,  Par.,  191 6,  v.  29,  pp.  466-469. 
Leri,  A.     Sur  les  accidents  nerveux  determines   par  la  deflagration  de  fortes 

charges  d'explosifs.     Rev.  neurol.  Par.,  1916,  v.  29,  pp.  586-587. 
Leri,   A.     Reformes,   incapacites,    gratifications,   dans   les   nevroses   de   guerre. 

Rev.  neurol..  Par.,  1916,  xxiii,  pp.  763-766. 
Leri,  A.     A  propos  de  I'hysterie.     Sur  un  cas  d'hemianesthesie  organique  presque 

pure.     Paris  med.,  1916  (Part  med.),  v.  19,  pp.  531-534. 
Leri,  A.     Les  commotions  des  centres  nerveux  par  eclatement  d'obus.     Rev.  gen. 

de.  path,  de  guerre,  1916,  No.  2,  pp.  169-212. 
Leri,  A.     fipilepsie  jacksonienne  par  "  vent  d'obus  "  (hemorragie  corticale  prob- 
able).    Presse  med.,  Par.,  1916,  v.  24,  p.  96. 
Leri,  A.     Traumatisme  du  crane;  hemiparesie  droite,  grosse  hemiatrophie  post- 

hemiplegique  avec  hemiatrophie  linguale  homolaterale;   syndrome  protube- 

rantiel  probable.     Rev.  neurol.,  Par.,  1917,  v.  24,  pp.  561-563. 
Leri,   A.     Procede  bi-photographique  pour  mesurer   revolution   progressive  ou 

regressive  des   paralysies   et   pour   etudier  les   mouvements   des   membres. 

Rev.  neurol..  Par.,  1917,  v.  24,  pp.  563-564. 
Leri,  A.     Emotions  et  commotions  de  guerre.     Collection  Horizon,  Masson  et 

Cie,  1918. 
Leri,  A.  and  Dagnan-Bouvert.     Soc.  de  Neurol.  May  6,  191 5.     Rev.   Neurol., 

July,  1915. 
Leri,  Froment  et  Mahar.     Atrophic  musculaire  et  deflagration  d'obus  sans  trau- 
matisme apparent.     Rev.  neurol.,  1914-15,  v.  222,  p.  754. 
Leri,  A.  et  Roger,  Edouard.     Sur  la  pathogenie  de  certains  oedemes  soidisant 

traumatiques.     Rev.  neurol.,  Par.,  1914-15,  v.  22^,  pp.  756-759. 
Leri,  A.  et  Roger,  E.     Sur  quelques  varietes  de  contractures  post  traumatiques 

et  sur  leur  traitement.     Bull,  et  mem.  soc.  med.  d'hop.  de  Par.,  1915,  v.  39, 

pp.  885-8941. 
Leri,  A.   et   Schaeffer,  H.      Hematobulbie  par  commotion;    survie;    syndrome 

bulbaire  complexe.     Soc.  med.  d'hop..  Par.,   1916,  26  mai. 
Leri  et  Schaeffer.     Hemorragies  du  nevraxe  par  commotion.     Presse  med.,  Par., 

1916,  V.  24,  pp.  351. 


BIBLIOGRAPHY  945 

Leri,  A.  et  Schaeffer.^    Un  cas  de  lesion  bulbo-medullaire  par  commotion  due  k 

un  eclatement  d'obus  hematobulbie  probable  survie  avec  syndrome  bulbaire 

complexe.     Rev.  neurol.,  Par.,  1917,  v.  24,  pp.  1-8. 
Leriche,  Rene.     De  la  causalgie  envisagee  comme  une  ndvrite  du  sympathique  et 

de  son  traitement  par  la  denudation  et  I'ablation  des  plexus  nerveux  peri- 

arteriels.     Soc.  de  Neurol.  6  Janvier  1916. 
Leriche,  R.     Des  lesions  cerebrales  et  medullaires  produites  par  I'explosion  k 

faible  distance  des  obus  de  gros  calibre.    Lyon  chirurg.,  1915,  v.  12,  pp  343- 
.  .350. 
Leriche,  R.     Des  petites  plaies  du  crane  par  eclates  d'obus  et  de  bombes  sans 

penetration  du  projectile  et  des  lesions  nerveuses  que  les  accompagnent. 

Lyon  chirurg.,  1915,  v.  12,  pp.  293-342. 
Leriche,  R.     De  la  sympathectomie  peri-arterielle  et  de  ses  resultats.      Presse 

med.,  Par.,  1917,  v.  25,  pp.  513-515. 
Lennoyez,  MarceL     La  surdite  de  guerre.     Presse  med..  Par.,  191 5,  v.  23,  pp. 

57-59- 
Leroy.     Sur  les  accidents   nerveux  determines  par  la  deflagration   de   fortes 

charges  d'explosifs.     Rev.  neurol.  Par.,  1916,  v.  29,  pp.  595-597. 
Lesietir  et  Peuret,  A.     L'insomnie  nerveuse  dite  essentielle  et  son  traitement 

medicamenteux.     Caducee,  Par.,  1917,  v.  17,  p.  96;  Bull,  med.,  Par.,  1917, 

v.  31,  pp.  12-13. 
Lesions  of  peripheral  nerves  resulting  from  war  injuries:  Pathology  and  treat- 
ment.    Brit.  Med.  Jour.,  1918,  i,  379,  408. 
Levy,  L.     Note  sur  les  renseignements   cytologiques   donnes  par  la  ponction 

lombaire  au  cours  de  revolution  des  blessures  du  crane.     Lyon  chirurg., 

1916,  V.  13,  pp.  428-433. 
Levy,  R.     Ueber  die  Resultate  der  Kaufmann'schen  Behandlung.     Miinch.  med. 

Wchnschr.,  1917,  v.  64,  No.  6. 
Levy-Valensi,  J.     Notes  sur  quelques  faits  cliniques.     Presse  med.,  191 5,  v.  23, 

pp.  179-181. 
Levy-Bing  et  Gerbay.     Epilepsia  syphiHtica.     Ann.  d.  mal.   ven..  Par.,   1917, 

12,  265-8. 
Lewandowsky,   M.      Die  Kriegsverletzungen  des  Nervensystems.      Berl.   klin. 

Wchnschr.,  1914,  v.  51,  pp.  1929-1934. 
Lewandowsky,  M.     Ueber  Kriegsverletzungen  des  Nervensystems.     i.  Gehirn- 

schiisse.     2.  Riickenmarksverletzungen.     4.  Hysterie.     Neurol.    Centralbl., 

Leipz.,  19 1 5,  V.  34,  pp.  47-48. 
Lewandowsky,    M.     Kriegsverletzungen   des    Nervensystems.     Deutsche    med. 

Wchnschr.,  Berl.  u.  Leipz.,  191 5,  v.  41,  pp.  29. 
Lewandowsky,  M.     Erfahrungen   iiber  die  Behandlung   nervenverletzter   und 

nervenkranker  Soldaten.     Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915, 

V.  41,  pp.  1 565-1 567. 
Lewandowsky,    M.     Familiare    Kaltelahmung.     Berl.    klin.    Wchnschr.,    1916, 

No.  5,  pp.  120. 
Lewandowsky,  M.     Ein  Fall  von  Rindenepilepsie  und  Rindenschwache.     Aerztl. 

Sachvert.  Ztg.,  Berl.,  1916,  No.  3.     Rev.  Berl.  klin.  Wchnschr.,  1916,  No.  12, 

p.  316. 
Lewis,  E.  R.     Influence  of  altitude  on  the  hearmg  and  the  motion-sensmg  ap- 
paratus of  the  ear.     Jour.  A.  M.  A.,  1918,  Ixxi,  1398. 
Lewis,  Thomas.     Observations  upon  Prognosis:     "Irritable  heart  of  soldiers." 

Lancet,  Lond.,  1918,  i,  pp.  181-183. 
Lewis,  Thomas.     Tolerance  of  physical  exertion,  as  shown  by  soldiers  suffering 

from  so-called  "  irritable  heart."     Brit.  Med.  Jour.,  1918,  i,  363. 
Lewitus.     Ein  seltener  Simulationsfall.     Wien.  med.  Wchnschr.,  1915,  No.  24, 

p.  925. 
Lhennitte,   J.     Hemiplegie  secondaire  aux  blessures  du  cr&ne.     Rev.  neurol., 

Par.,  1916,  V.  24,  pp.  807-813. 
Liebault,  G.     Les  troubles  de  la  parole  et  les  commotions  de  guerre.     Rev.  gen. 

de  path,  de  guerre,  1916,  No.  3,  pp.  245-269. 
Liebers,  M.     Zur  Behandlung  der  Zitterneurosen  nach  Granatschock.     Neurol. 

Centralbl.,  Leipz.,  1916,  v.  35,  No.  21. 
Liebl.     Ein    charakteristisches     kiinstlich    erzeugtes     Geschwiir.     Wien.     klm. 

Wchnschr.,  1916,  xxix,  1305. 


946 


BIBLIOGRAPHY 


Liepmann,  H.     Psychiatrisches  aus  dem  Russ.-Jap.  Feldzug.      Deutsche  med. 

Wchnschr.,  Bed.  u.  Leipz.,  1914,  v.  40,  pp.  1823. 
Liepmann,  H.     Zur  Fragestellung  in  dem  Streit  iiber  die  traumatische  Neurose. 

Neurol.  Centralbl.,  Leipz.,  1916,  v.  35,  No.  6. 
Loeper,  M.  et  Carlotti,  J.     Pustule  maligne  des  paupieres  a  guerison  rapide. 

Progres  med.,  Par.,  1916,  No.  3,  pp.  17-19-, 
Loeper,  M.  and  Verpy,  G.     Les  troubles  vasculaires  et  hematiques  de  la  commo- 
tion.    Compt.  rend.  Soc.  de  biol..  Par.,  1916,  Ixxix,  pp.  831-833. 
Loeper,  M.  et  Verpy,  G.     La  repercussion  glandulaire  et  humorale  des  commo- 
tions.    Progres  med..  Par.,  1916,  v.  21,  pp.  202-205. 
Logre,  M.     Debut  de  paralysie  generale  avec  tabes  par  des  crises  de  poltron- 

nerie  avec  incontinence  d'urine.     Presse  med.,  Par.,  1917,  v.  25,  p.  395. 
Lollet.     Discussion  de  la  conduite  k  tenir  vis-i-vis  des  blessures  du  crane  —  par 

P.  Marie.  Rev.  neurol..  Par.,  1916,  v.  29,  p.  470. 
Lombard   et   Baldenweck.     Traitement   de   quelques   cas   de    mutite   hystero- 

traumatique  par  le  procede  de  la  suppression  de  controle  auditif  de  la  voix 

(methode  de  Lombard).  Presse  med..  Par.,  1915,  v.  23,  p.  338. 
London  War  Hospitals,  Boston  M.  and  S.  J.,  1917,  i,  pp.  222-223. 
Long,  E.     Radiculite  lombo-sacree  (sciatique  radiculaire)  d'origine  syphilitique. 

Rev.  neurol.  Par.,  1916,  v.  29,  pp.  298-300. 
Loreta,   U.     Per   I'applicazione   di   esami    psicologici    nell'    esercito.      Policlin., 

Roma,  1915,  c.  17,  sez.  prat.,  pp.  1298-1300. 
Lortat- Jacob.     Le  syndrome  des  eboules.     Rev.  neurol.  Par.,  1914-15,  v.  22^, 

pp.  1173. 
Lortat- Jacob.     Discussion  de  la   conduite    k  tenir   vis-^-vis    des    blessures   du 

crane  —  par  P.  Marie.  Rev.  neurol.,  Par.,  1916,  v.  29,  p.  470. 
Lortat- Jacob.     Sur   les   accidents   nerveux   determines   par   la   deflagration   de 

fortes  charges  d'explosifs.     Rev.  neurol.  Par.,  1916,  v.  29,  pp.  590-591. 
Lortat- Jacob  et  Buvat,  J.  B.     Sur  un  procede  de  guerison  des  sourds-muets  par 

commotion.     Bull,  et  mem.  de  soc.  med.  d'hop.  de  Par.,  1916,  pp.  169-176; 

Rev.  Paris  med.,  1916  (Part,  med.),  v.  19,  p.  226. 
Lortat- Jacob  et  Sezary.     Synesthesialgie  et  blessure  du  sciatique.     Rev.  neurol., 

1914-15,  V.  22^  pp.  1277-1278. 
Lortat- Jacob  et  Sezary.     Maladie  de  Thomsen.     Rev.  neurol.,  Par.,  1916,  v.  23, 

pp.  15-18. 
Lortat- Jacob  et  Oppenheim,  R.     Hemiplegie  post-scarlatineuse.     Progres  med., 

Par.,  1916,  pp.  213-215. 
Lortat,  Jacob  et  Oppenheim,  R.  et  Toumay,  A.     Topographie  des  modifications 

de  la  sensibilite  au  cours  des  troubles  physiopathiques;   constitution  d'un 

syndrome  radiculo-sympathique  reflexe.     Progres  med..  Par.,  191 7,  No.  10, 

pp.  77-81. 
Love,  K.     Hearing  in  the  Army.     J.  Roy.  Army  Med.  Corps,  Lond.,  1915,  v.  27, 

pp.  652-654. 
Lowenfeld.     tJber  den  franzosischen  Nationalcharakter   und   seine  Auswiichse 

im    gegenwartigen    Kriege    (Psychopathia    gallica).      Allgem.    Zeitschr.    f. 

Psychiat.,  Wiesbaden,  1914. 
Lowenstein,  Kurt.     Zerebellare  Symptomenkomplexe  nach  Kriegsverletzungen. 

Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  626-637, 
Lowenstein,   Sally.     Zur  traumatischen  Entstehung  chronischer  Riickenmarks- 

leiden.     Neurol.  Centralbl.,  37,  Nr.  16,  1918. 
Lowy,  Max.     Neurologische  und  psychiatrische  Mitteilungen  aus  dem  Kriege. 

Monatschr.  f.  Psychiat.  und  Neurol.,  Berl.,  1915,  v.  37,  pp.  380-388. 
Lowy,  Julius.     Uber  die  Beeinflussung  von  Erkrankungen  des  Nervensystem 

durch  den  Apparat  von  Bergonie.     Ztschr.   f.   Phys.   u.    Diatet.  Therap., 

Leipz.,  191 5,  No.  9,  pp.  272-276. 
Lumiere,  Augusta  et  Astier.     Cerebral  troubles  in  tetanus.     Monde  Med.,  Par., 

1917,  V.  27,  pp.  101-105. 
Limisden,  T.     The  psychology  of  malingering  and  functional  neuroses  in  peace 

and  war.     Lancet,  Lond.,  1916,  ii,  pp.  860-862.     Rev.  Boston  M.  and  S.  J., 
|J9i6,  ii,  p.  8. 
Lumpen,  T.     Treatment  of  war  neuroses.     Lancet,  Lond.,  1917,  ii,  p.  804. 
Lumsden.  T.     Shell  Shock.     (A  letter.)     Lancet,  Lond.,  1917.  i-  D.  .^4. 


BIBLIOGRAPHY  947 

Lumsden's  scheme  for  treatment  of  nerve-shattered  soldiers.    Hospital,  Lend., 

1917,  V.  61,  pp.  487-488. 

Lust,   F.     Kriegsneurosen    und    Kriegsgefangene.      Miinch.    med.    Wchnschr., 

191 6,  V.  63,  p.  1829. 
Lyonnet.     Un  cas  de  paraplegic  d'origine  cerebrale.     Lyon  med.,  191 5,  v.  124, 

pp.  362-363. 
Lyle,  H.  H.  M.     Physiological  treatment  of  bullet  and  shell  wounds  of  the  peri- 
pheral nerve  trunks.     S.  G.  O.,  191 6,  xxii,  127. 
Lyristritski,  V.  V.     (Psychical  symptoms,  difficult  to  simulate).     Psikhiat.  Gaz., 

Petrogr.,  1915,  v.  2,  pp.  121-124. 
MacAulifie,  Leon.     Evolution  de  I'etat  commotionnel  chez  les  blesses  du  cr&ne 

trepanes.     Paris  med.,  1917,  No.  47,  pp.  421-424. 
MacCurdy,  John  T.     The  Psychology  of  War.     Wm.  Heinemann,  1917. 
MacCurdy,  John  T.     War  Neuroses.     Cambridge  Univ.  Press,  1918. 
MacCurdy,  John  T.     War  neuroses.     Psychiat.  Bull.,  Utica,  1917,  v.  2,  No.  3, 

pp.  243-254. 
Macdonald,  W.  M.     Contractions  of  the  hand  after  wounds  of  the  upper  limb. 

Brit.  M.  J.,  Lond.,  1916,  ii,  pp.  209-212. 
MacDonald,  W.  M.     Tinel's  sign  in  peripheral  nerve  lesions.     Brit.  Med.  Jour., 

1918,  ii,  6. 

Mackenzie,  W.  C.     Military  orthopaedic  hospitals.     Brit.  M.  J.,  Lond.,  1917, 

V.  I,  pp.  669-678. 
MacKenzie,  Kenneth  A.  J.     Repair  of  large  gaps  in  peripheral  nerves  by  neuro- 

plasty.     Surg.  Gynecol,  and  Obstet.,  1918,  xxvii,  355. 
MacLeod,  Kenneth.     Dreaming.     Med.  Press  and  Circ,  Lond.,  1916,  v.  102, 

pp.  98-100. 
MacMahon,  Cortlandt.     Shell  shock,  stammering  and  other  affections  of  voice 

and  speech.     J.  Roy.  Army  Med.  Corps,  Lond.,  1917,  v.  39,  pp.  192-201. 
Madelung.     Kriegsarztliche  Erfahrungen  im  England  und  Frankreich.     Miinch. 

med.  Wchnschr.,  v.  62',  pp.  283-284. 
V.  Maiendorf.     Uber  Kriegsneurosen.     Wien.  klin.  Wchnschr.,  1915,  v.  38^,  pp. 

79-80. 
Mairet,  A.  et  Durante,  G.     Contribution  a  I'etude  experimentale  du  syndrome 

commotionnel.     Rev.  neurol..  Par.,  1917,  v.  24,  pp.  456-466. 
Mairet,  A,  et  Durante,  G.     Etude  experimentale  du  syndrome  commotionnel. 

Presse  med..  Par.,  191 7,  v.  25,  p.  478. 
Mairet  et  Pieron.     Les  troubles  de  memoire  d'origine  commotionnelle.     J.  de 

psychol.  norm,  et  path..  Par.,  1915,  v.  No._2,  pp.  300-328. 
Mairet  et  Pieron.     Acces  epileptiques  determines  par  une  irritation  nerveuse 

peripherique.     Rev.  Paris  med.,  1916  (Part  med.),  v.  19,  p.  178. 
Mairet  et  Pieron.     De  la  difTerenciation  des  symptomes  "  commotionels  "  et  des 

symptomes  "  atypiques  "  dans  les  traumatismes  crinio-cerebraux.  Monpel. 

med.,  1916,  V.  39,  p.  174. 
Mairet  et  Pieron.     De  quelques  problemes   poses  par  la  neuropsychiatrie  de 

guerre  au  point  de  vue  des  reformes.  Montpel.  med.,  191 6,  v.  39,  pp.  387- 

402. 
Mairet,  A.   et  Pieron,  H.     Syndr6me  epileptique  par  irritation  nerveuse  per- 
ipherique ou  "  Epilepsie  de  Brown-Sequard."     Bull.  acad.  de  med..  Par., 

1916,  V.  75,  pp.  80-90. 
Mairet,  A.  et  Pieron,  H.     De  quelques  problemes  poses  par  la  neuropsychiatrie 

de  guerre  au  point  de  vue  des  reformes.     Paralysies  generales,  crises  d'epi- 

lepsie   apparues   ou   aggravees   acces   de  somnambulisme,   accidents   apres 

vaccination  antityphoidique.     Rev.  neurol..  Par.,  1917,  y.  24,  pp.  89-98.^ 
Mairet  et  Pieron.     Le  syndrSme  emotionnel.     Sa  differenciation  du  syndrome 

commotionnel.     Rev.  neurol..  Par.,  19171  v.  24,  pp.  474-475. 
Mairet,  A.  and  Pieron,  H.     Le  syndrome  commotionnel.     Ibid.,  p.  345. 
Mairet,  A.  et  Pieron,  H.     Le  syndrome  emotionnel;    sa  differenciation  du  syn- 
drome commotionnel.     Montpel.  med.,  1917,  v.  39,  pp.  581-599. 
Mairet,  A.  et  Pieron,  H.    Le  syndrome  emotionnel :  sa  differenciation  du  syndrdme 

commotionnel.     Ann.  med. -psychol.,  1917,  v.  73,  pp.  183-206. 
Mairet,  A.  et  Pieron,  H.  et  Mme.  Bouzansky.     De  I'existence  d'un  "  syndrome 

commotionnel  "  dans  les  traumatismes  de  guerre.     Bull,  de  acad.  de  med., 

Par.,  1915,  V.  73,  pp.  654-661. 


948  BIBLIOGRAPHY 

Mairet,  Pieron  et  Bouzansky.  Des  variations  du  "  syndrome  commotionnel," 
suivant  la  nature  des  traumatismes,  et  de  son  unite.  Bull,  de  I'acad.  de 
med.,  Par.,  1915,  v.  73,  pp.  690-700. 

Mairet,  Pieron  et  Bouzansky.  Le  "  syndrome  commotionnel  "  au  point  de  vue 
du  mecanisme  pathogenique  et  de  revolution.     Bull,  de  acad.  de  med.,  Par., 

1915.  V.  73.  PP-  710-716. 

Mahomet.     Treatment  by  physical  methods  of  mental  disabilities  induced  by 

the  war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10,  (sect.  Balneol.),  p.  42. 
Maitland,  T.   J.     Accumulated   fatigue   in   warfare.     (2nd   int.   rep.,  Brit.  Ass. 

Comm.)  Lancet,  Lond.,  1916,  ii,  pp.  995-956. 
Malingering  in  the  French  Army.     Brit.  M.  J.,  Lond.,  1916,  i,  p.  64. 
Malingering.     Brit.  M.  J.,  Lond.,  1917,  ii,  p.  117.     Malingering  in  the  army. 

Monde  med.,  Paris,  1916.     Eng.  ed.,  xxvi,  p.  147. 
Mallet,  R.     A  propos  de  quelques  psychopathes.     Presse  med.,  Par.,  1915,  v.  23, 

p.  390. 
Mallet,  R.     Troubles  psychiques  et  hallucinations  chez  le  combattant.     Progres 

med..  Par.,  1916,  No.  3,  p.  16. 
Mallet,  R.     Troubles  psychiques  et  hallucinations  chez  le  combattant.     Rev. 

Paris  med.,  1916  (Part,  med.),  v.  19,  p.  96. 
Mallet,  R.     Troubles  d'origine  emotive  chez  le  combattant.     Presse  med..  Par., 

1916,  V.  24,  p.  95._ 

Mallet,  R.     La  confusion  mentale  chez  le  combattant.     Presse  med.,  Par.,  1916, 

V.  24,  pp.  294-295. 
Mallet,  R.     Fugues  des  degeneres.  Presse  med.,  Par.,  v.  24,  1916,  p.  493. 
Mallet,  R.     Discussion  de  Vincent.     Rev.  neurol.  Par.,  Nos.  4-5,  p.  597. 
Mallet,  R.     Fugues  et  delires  aigus.  Rev.  neurol.,  191 7,  v.  24,  p.  486. 
Mallet,  R.     Etats  du  fatigue.     Presse  med.,  Par.,  191 7,  v.  25,  p.  325. 
Mallet,  R.     Etats  confusionnels  et  anxieux  chez  le  combattant.     Ann.   meo. 

psychol..  Par.,  191 7,  y.  73,  pp.  27-35. 
Mallet,  R.     Fugue  et  delire.     Contribution  a  I'etude  des  troubles  psychiques  de 

la  guerre.     Ann.  med.  psychol..  Par.,  1917,  v.  73,  pp.  330-343. 
Mally  and  Corpechot.     Monomyoplegies  traumatiques;  etude  sur  un  groupe  de 

lesions  du  systeme  nerveux  peripherique  causees  par  les  projectiles  modernes. 

Rev.  de  Chir.,  1917,  Hi,  281. 
Mann,  G.     Die  traumatischen  Neurosen,  ihre  Entstehungsweise  und  klinischen 

Formen  bei  Kriegsverletzten.     Deutsche  med.  Wchnschr.,  Leipz.  u.  Berl., 

1916,  V.  42,  p.  1563. 
Mann,  G.     Neue  Gesichtspunkte  und  Methoden  zur  Behandlung  der  Kriegsneu- 

rosen.     Med.  Klin.,  Berl.,  1916,  v.  12,  p.  1270. 
Mann,   L.     Uber   Polyneuritis   als    Begleiterscheinung   nervoser   Erschopfungs- 

zustande  im  Kriege.     Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  150-152. 
Mann,  L.     Uber  Granatexplosionsstorungen.     Med.  Klin.,  Berl.  u.  Wien.,  1915, 

V.  II,  pp.  963-964- 
Mann,  L.     Neue  Methoden  und  Gesichtspunkte  zur  Behandlung  der  Kriegsneu- 

rosen.     Berl.  klin.  Wchnschr.,  1916,  No.  50,  pp.  1333-1338. 
Mann,  L.     Die  traumatischen  Neurosen,  ihre  klinischen  Formen  und  ihr  Entste- 

hungsmodus  bei  Kriegsverletzungen.     Berl.   klin.   Wchnschr.,   1916,  v.   53, 

No.  37,  and  No.  38. 
Mann,  L.     Zur  Frage  der  traumatischen  Neurosen.     Wien.   klin.  Wchnschr., 

1916,  xxix,  1 65 1. 
Mann,  Lillienstein,  etc.     Discussion;   Neurosen  nach  Kriegsverletzungen.     Berl. 

klin.  therap.  Wchnschr.,  Wien  u.  Berl.,  1916,  v.  49-50,  pp.  486-496. 
Mannell,  J.  D.     Reeducation  in  walking.     Hospital,  Lon.,  191 7,  Ixi,  383. 
Marage.     Les  sourds-muets  de  guerre.     Academie  des  Sciences,  25  avril  191 5. 
Marage.     Reeducation  auditive  des  surdites  consecutives  a  des  blessures  de 

guerre.     Vigot  freres,  1915. 
Marage.     Contribution  a  I'etude  des  hypo-acousies  consecutives  k  des  blessures 

de  guerre.     Compt.  rend.  acad.  d.  sc,  Par.,  1915,  v.  161,  pp.  148-150. 
Marage.     Traitement  des  hypo-acousies  consecutives  k  des  blessures  de  guerre. 

Compt.  rend.  acad.  d.  sc.  Par.,  1915,  v.  161,  pp.  319-322. 
Marage.     Les  sourds-mutites  vraies  et  simulees  consecutives  a  des  blessures  de 

guerre.     Compt.  rend.  acad.  d.  sc.  Par.,  1916,  v.  162,  pp.  651-654. 


BIBLIOGRAPHY  949 

Marage,   M.     Classement   des   soldats   sourds   d'ipr^s   leur   degre   d'audition. 

Compt.  rend.  acad.  d.  sc,  Par.,  1916,  v.  162,  pp.  801-804. 
Marage.     Douze  mois  de  reeducation  auditive  dans  Tarmee;  resultats  de  250  cas. 

Bull.  acad.  de  med.,  Par.,  1916,  v.  76,  pp.  318-320. 
Marage.     La  reeducation  des  surdites  consecutives  k  des  blessures  de  guerre. 

Bull.  gen.  psychol..  Par.,  1916,  v.  15,  pp.  5-21. 
Marage.     Traitement  de  la  surdite  par  commotion.     Paris  med.,  1916,  (Part. 

med.),  V.  21,  p.  419. 
Marbiirg.     Zur  Frage  der  Beurteilung  traumatischer  Neurosen  im  Kriege.     Wien. 

klin.  Wchnschr.,  1916,  v.  29,  pp.  281-282. 
Marburg,    O.     Nervose    Folgezustande    von    kriegerischen    Ereignissen.     Mili- 

tararzt,  Wien,  1914,  xlviii,  pp.  402-404. 
Marchal,  R.     Les  lesions  des  nerfs  peripheriques.     Arch.  med.  beiges.       Paris, 

1917,  70,  44. 
Marchand,  L.     Des  troubles  mentaux  dans  les  blessures  penetrantes  du  cr§.ne. 

Ann.  med.  psychol.,  Par.,  1916-17,  v.  7,  pp.  192-208. 
Marchand,  L.     Des  paraplegics  hysteriques  consecutives  aux  polyneurites  diph- 

teriques.     Bull,  et  mem.  Soc.  med.  hop.  de  Paris,  191 7,  3  ser.  41,  pp.  248-53. 

Maresch.     Uber  Schadelschiisse.     Wien.  klin.  Wchnschr.,  1915,  v.  28,  pp.  1208- 

1231. 
Margulies,  A.     Nervenerkrankungen  im  Kriege.     Prag.  med.  Wchnschr.,  1915, 

v.  40,  pp.  299-301. 

Marie,  Pierre.     A  propos  d'un  prisonnier  de  guerre  simulateur.     Rev.  neurol.. 

Par.,  1914-1915,  V.  22\  p.  492. 
Marie,  P.     Sur  la  frequence  relative  des  amelioration  dans  les  cas  de  quadri- 

plegie  par  traumatisme  meduUaire,  due  a  une   blessure  de  guerre.      Bull. 

acad.  de  med..  Par.,  1915,  v.  73,  pp.  675-678. 
Marie,  P.     La  conduite  k  tenir  vis-^-vis  des  blesses  du  crane.     Rev.  neurol..  Par., 

1916,  v.  29,  pp.  453-457- 
Marie,  P.     Tetanos  tardif  localise  a  type  abdominothoracique.      Paris  med., 

1916,  v.  21,  pp.  49-51. 
Marie,  P.  et  Benisty,  A.     Troubles  nerveux  purement  fonctionnels  consecutifs 

k  des  blessures  de  guerre.     Rev.  neurol..   Par.,   1914-15,  v.  22^,  pp.  424- 

.425- 

Marie  et  Benisty.  Remarques  cliniques  sur  quelques  cas  de  lesions  de  la  moelle 
cervicale  par  plaies  de  guerre.     Rev.  Paris  med.,  (Part,  med.),  v.  17,  p.  178. 

Marie  et  Benisty.  Du  retour  de  la  contractilite  faradique  avant  le  retablissement 
de  la  motilite  volontaire  dans  les  muscles  paralyses,  a  la  suite  des  lesions  des 
nerfs  peripheriques.  Soc.  de  Neurol,  de  Paris,  1915.  Revue  Neurol.  May- 
June  1915,  and  July  1915. 

Marie  and  Benisty.  Individualite  clinique  des  nerfs  peripheriques.  Soc.  de 
Neurol.     March  15,  1915.     Revue  neurol,  May-June  1915. 

Marie  and  Benisty.  Une  forme  douloureuse  des  lesions  de  nerf  median  par  plaie 
de  guerre.     Academie  de  Med.,  Mar.  16,  191 5. 

Marie,  P.  et  Chatelin.  Un  cas  d'hematomyelie  par  eclatement  d'obus  a  distance. 
Rev.  neurol.,  Par.,  1914-15,  v.  22^,  p.  777. 

Marie,  P.  et  Chatelin.  Notes  sur  une  variete  de  troubles  de  la  parole  (scansion) 
observee  dans  les  blessures  de  la  region  frontale.  Rev.  neurol..  Par.,  1917, 
V.  24,  pp.  135-136. 

Marie,  P.;  Chatelin  et  Patrikios.  Paralysie  generale  progressive  developpee  chez 
un  jeune  soldat  pendant  la  guerre.     Rev.  neurol.,  Par.,  1917,  v.  24,  p.  38. 

Marie,  P.,  Dejerine,  Ballet,  G.,  Thomas,  A.,  Dupre;  Babinski,  J.,  Meige,  H. 
Discussion  sur  les  troubles  nerveux,  dits  fonctionnels,  observes  pendant  la 
guerre.     Rev.  neurol.,  Par.,  1914-15,  v.  22\  pp.  447-452. 

Marie,  P.  et  Foix.  Sur  une  forme  speciale  de  paresie  paratonique  des  muscles 
moteurs  de  la  main.     Soc.  med.  d'hop.,  1916,  10  fevrier. 

Marie  et  Foix.  Les  syncinesies  des  hemiplegiques  etude  semeiologique  et  classi- 
fication.    Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  2-27. 

Marie  et  Foix.  Influence  du  froid  et  des  troubles  vasomoteurs  sur  les  reactions 
electriques.     Rev.  neurol..  Par.,  IQ16,  v.  29,  pp.  921-923. 

Marie  et  Foix.  Indications  operatoires  fournies  par  I'examen  histologique  des- 
nerfs  leses  par  plaies  de  guerre.     Presse  Med.,  Jan.  31,  1916. 


950  BIBLIOGRAPHY 

Marie  et  Meige.     Appareils  pour  blesses  nerveux.      Academie  de  Medecine, 

1915-  .      .  .        , 

Marie,  Meige,  et  Gosset.     Les  localisations  motnces  dans  les  nerfs  peripheriques. 

Academie  de  Medecine,  Dec.  28,  1915. 
Marie,  P.  et  Foix.     Les  aphasies  de  guerre.     Rev.  neurol.,  Par.,  191 7,  v.  24,  pp. 

53-87-  ,  

Marie,  P.  et  Mile.  G.  Levy.     Un  cas  d'hemiplegie  organique  par  commotion  sans 

blessure.     Rev.  neurol..  Par.,  1917,  v.  24,  pp.  44-45. 
Marie,  P.,  Meige,  H.,  et  Behague,  P.     Necessite  d'un  examen  neurologique  des 

plicatures  dorsaux  (camptocormiques).     Rev.  neurol.,  Par.,  191 7,  v.  24,  pp. 

129-130. 
Marriage,   H.  J.      Special  discussion  on  warfare  injuries  and  neuroses.     Proc. 

Roy.  Soc.  Med.,  Lond.,  1917,  v.  10,  (sect.  Otol.),  pp.  47-56. 
Marshall,   W.   H.     Shell  shock.     J.  Mich.    M.   Soc,  Detroit,    191 7,  Sept.,  pp. 

396-399. 
Martinet,  Alfred.     Guerre  et  nevroses  cardiaques.     Presse  med.,  Par.,  1915,  v. 

23,  PP-  433-435- 
Martyn,  King.     Treatment  by  physical  methods  of  mental  disabilities  induced  by 

the  war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10,  (sect.  Balneol.), 

pp.  19-21. 
Marx,  S.     Uber  funktionelle  Stimm-  und  Sprachstorungen  und  ihre  Behandlung. 

Miinchen  med.  Wchnschr.,  1916,  No.  42,  pp.  1 502-1 503. 
Massachusetts  conunittee  for  the  State  Care  and  Treatment  of  Soldiers  Suffering 

from  Nervous  and  Mental  Diseases  (letter).     Bos.  M.  &  S.  J.,  1917,  clxxvi, 

922. 
Mathieu,  Albert.     Cause  psychique  de  vomissements  excessifs  apres  la  chloro- 

formisation  et  apres  la  gastro-enterostomie.     Presse  med.,  Par.,  1917,  v.  25, 

PP-  ^97- 
Matirij  A.     I  disturbi  mentali  nella  sclerosi  laterale  amiotrofica.     Riv.  crit.  di 

clin.  med.,  Firenze,  1916,  v.  17,  pp.  197,  209,  221,  233. 
Mauclaire,  PI.     Troubles  moteurs  d'origine  psychiques  chez  les  blesses  militaires. 

Bull,  et  mem.  soc.  de  chir.  de  Par.,  1914,  v.  40,  p.  1290. 
Mauclaire,  PI.     Commotion  cerebrale  intense  avec  mutisme  et  surdite  psychiques. 

Bull,  et  mem.  soc.  de  chir.  de  Par.,  1916,  v.  42^  pp.  140-141. 
Maude,  A.     Influenza  and  purulent  bronchitis.     Lancet,  Lon.,  1918,  ii,  324. 
Mayeadorf.     Uber   pathologische    Zitterformen    zur    Kriegszeit.   Miinch.  med. 

Wchnschr.,  1916,  v.  63,  p.  323. 
Mayer,  A.  G.     On  the  non-existence  of  nervous  shell-shock  in  fishes  and  marine 

invertebrates.     Proc.  Nat.  Acad.  Sc,  Bait.,  191 7,  iii,  p.  597. 
Mayer,    C.     Behandlung    gekommenen   Falle   von    Kriegsverletzungen.     Wien. 

med.  Wchnschr.,  1915,  v.  65,  p.  37. 
Mayer,  C.     Kriegsneurologische  Erfahrungen.     Med.  Klin.,  Berl.  u,  Wien.,  1915, 

V.  ii^,  pp.  1017-1022. 
Mayer,  Leo.     Autoplastic  nerve  transplantation  in  the  repair  of  gunshot  injuries. 

Surg.  Gynecol,  and  Onstet.,  1918,  xxvii,  530. 
Mayer,  L.     Organization  and  aims  of  the  Orthopedic  Reconstruction  Hospital. 

Amer.  Jour.,  Care  for  Crip.,  1917,  78. 
Maynard.     Syndrome    psychique    atypique    chez    les    blesses  cranio-cerebraux. 

Montpel.  med.,  1916,  v.  39,  pp.  65-69. 
Mayo-Robson,  A.  W.     Treatment  of  paraplegia  from  gunshot  or  other  injuries 

of  the  spinal  cord.     Brit.  Med.  Jour.,  1917,  ii,  853. 
McArdle,   J.   S.     Joint  troubles  arising  from  nervous  diseases.     Practitioner, 

Lond.,  1915,  V.  95,  pp.  174-180. 
McClure,  J.  Campbell.     The  manipulation  bath.     Proc.  Roy.  Soc.  Med.,  Lond., 

1917,  V.  10,  No.  9  (Sect,  of  B.  and  Climatology),  pp.  70-78. 
McClure,  J.  C.     Gastric  atony  and  war  neurasthenia.     Lancet,  Lond.,  191 7,  ii. 

600-602. 
McDougall,  W.     Shell  shock  without  visible  signs  of  injury.     Proc.  Roy.  Soc. 

Med.,  Lond.,  1915-16,  v.  9  (Sect.  Psychiat.),  pp.  25-26. 
McDowall,  Colin.     Functional  gastric  disturbances  in  the  soldier.     J.  Ment.  Sc, 

Lond.,  191 7,  V.  63,  pp.  76-88. 
McDowall,    Colin.     Functional    gastric    disturbances    in    the    soldier.     Lancet, 

Lond.,  1916,  ii,  pp.  944-945. 


BIBLIOGRAPHY  95 1 

McEllroy,  W.  S.     Acidosis  in  shock.     Jour.  A.  M.  A.,  1918,  Ixx,  846. 

McKellar,  H.  R.     Malingering.     Mil.  Surgeon,  Wash.,  1916,  xxxix,  293-299. 

McKenzie,  R.  Tait.  Functional  reeducation  of  the  wounded.  N.  Y.  Med. 
Jour.,  1918,  cviii,  683. 

McKenzie,  R.  Talt.     Reclaiming  the  Maimed.     Macmillan,  19 18. 

McKenzie,  R.  Tait.  Treatment  of  convalescent  soldiers  by  physical  means, 
Bnt,  M.  J.,  Lond.,  1916,  ii,  pp.  215-218;  also  Proc.  Roy.  Soc.  Med.,  Lond., 
1915-16,  V.  9  (Surg.  Sect.),  pp.  31-70. 

McLaughlin,  J.     Loss  of  speech  and  shell  shock.     Lancet,  Lond.,  1916,  i,  212. 

McMurtie,  Douglas  C.     The  Disabled  Soldier.     Macmillan,  1919. 

McMurtrie,  D.  C.  Industrial  training  for  war  cripples.  Illustrations  of  educa- 
tional work  in  France  and  Germany.  Am.  J.  Care  Cripples,  N.  J.,  19 17, 
V.  4,  p.  16. 

McMurtrie,   D.    C,     Reeducating   German  war  cripples  at   Diisseldorf.     Bos 

M.  &  S.  J.,  1918,  clxxviii,  182. 
McWaLter,  J.  C.     A  note  on  commotio  cerebri,  or  shell  shock.     Med.  Press  and 

Circ,  Lond.,  1916,  v.  loi,  pp.  332-333. 
McWalter,  J.  C.     An  experiment  in  enforced  continence.     Med.  Press  and  Circ, 

Lond.,  1916,  V.  102,  pp.  363-364. 
Meakins,  J.  C.  and  Gunson,  E.  B.     Occurrence  of  hyperalgesia  in  the  "  irritable 

heart  of  soldiers."     Heart,  1917,  vi,  343. 
Medea,  E.     Malattie  nervose  e  malattie  mentali  in  rapporto  alia  guerra.     Osp. 

maggiore,  Milano,  1915,  2  s.,  v.  3,  pp.  399-408. 
Medea,  E.     Neurologia  di  Guerra.     Atti.  d.  Soc.  lomb.  di  sc.  Med.  e  Biol., 

Milano,  1915-16,  v.  5,  pp.  49-60. 
Medication  hypnotique  par  le  dial.     Progres  Med.,  Par.,  1916,  v.  31,  p.  56. 
Medecin  tire  par  un  aliene  qu'il  soignait.     Ann.  Med.-psychol.,  Par.,  1916-17, 

_  P-  567- 
Meige,  Henri.     De  certaines  boiteries  observees  chez  les  "  blesses  nerveux." 

Rev.  neurol.,  Par.,  1914-15,  v.  22,  pp.  939-947. 
Meige,  H.     Contractions  convulsives  des  muscles  peauciers  du  crane  a  la  suite 

d'une  deflagration  (Tic  ou  Spasme?)     Rev.  neurol..  Par.,  1916,  v.  23,  pp. 

107-109. 
Meige,  H.      Les  tremblements  consecutifs  aux  explosions.      Rev.  neurol.  Par., 

_  1916,  Nos.  4-5,  p.  592. 
Meige,  H.     Torticolis  convulsif  survenu  chez  un  blesse  du  crane  hemiplegique  et 

_  jacksonien.     Rev.  neurol..  Par.,  1916,  v.  23,  pp.  571-574. 
Meige,  H.     Reformes,  incapacites,  gratifications  dans  les  tremblements,  les  tics 

et  les  spasmes.     Rev.  neurol..  Par.,  1916,  v.  23,  pp.  758-763. 
Meige,  H.     Torticolis  convulsif  survenu  chez  un  blesse  du  crane  hemiplegique  et 

acksonien.     Rev.  neurol..  Par.,  1916,  v.  24,  pp.  571-574. 
Meige,  H.     Tremblement,  tressaillement,  tremophobie  consecutifs  aux  explo- 
sions.    Rev.  neurol..  Par.,  1916,  v.  29,  pp.  140-158. 
Me'ge,  H.     Les  tremblements  consecutifs  aux  explosions  (tremblement,  tressaille- 
ment, tremophcbie).     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  201-209. 
Meige,  H.     Sur  les  accidents  nerveux  determines  par  la  deflagration  de  fortes 

charges  d'explosifs.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  592-593. 
Meige,  H.     Appareil  pour  redresser  les  grifles  cubitales  (Appareil  Gillot).      Rev. 

neurol..  Par.,  191 7,  v.  24,  pp.  264-265. 
Meige  et  Mme.  Athanassio  Benisty.     De  I'importance  des  lesions  vasculaires 

associees  aux  lesions  des  nerfs  peripheriques  dans  les  plaies  de  guerre.     Bull. 

et  mem.  soc.  med.  d'hop.  de  Par.,  1915,  v.  39,  pp.  208-211. 
Meige  et  Benisty.     Les  formes  douloureuses  des  blessures  des  nerfs.     Soc.  de 

Neurol.,  July  i,  1915. 
Meige  et  Benisty.     Les  signes  cliniques  des  lesions  de  I'appareil  sympathique  et 

de  I'appareil  vasculaire  dans  les  blessures  des  membres.     Presse  med..  Par., 

1916,  V.  24,  pp.  153-156. 
Meige,  H.,   Benisty,  A.,   et  Levy,  G.     Impotence  de  tous  les  mouvements  de  la 

main  et  des  doigts,  avec  integrite  des  reactions  electriques   (main  figee). 

Rev.  neurol..  Par.,  1914-15,  v.  22,  pp.  1273-1276. 
Meige,   Mare,  T.,   etc.     Discussion  sur  la  camptocormie.      Rev.  neurol..  Par., 

1914-15,  V.  22^,  p.  1250. 


952  BIBLIOGRAPHY 

Melocchi,  F.  Importanza  dei  centri  fisiatrici  di  rieducazione  funzionale  per  gli 
invalid!  di  guerra.     Pensiero  med.,  Miiano,  1917,  v.  7,  p.  282. 

Mendel,  Kvirt.  Psychiatrisches  und  Xeurologisches  aus  dem  Felde.  Neurol. 
Centraibl.,  Leipz.,  1915,  No.  i,  p.  2.     Rev.  Med.  Klin.,  Berl.  u.  Wien.,  1915, 

V.    Ill,    p_   575. 

Mendelssolin,  Maurice.     Deux  cas  de  paraplegic  de  nature  organique  suivis  de 

guerison.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  190-193. 
Mental  and  nervous  cases  in  the  war.     Alb.  Sled.  Ann.,  1917,  xxxviii,  328. 
Mental  disabilities  for  war  service.     Lancet,  Lond.,  1916,  v.  191,  p.  234. 
Mentality  (fortitude)  of  Wounded.     Brit.  M.  J.,  Lend.,  1915,  i.  p.  980. 
Menzel.     Mobilisierung  in  ursachlichem  Zusammenhange  stehenden  Xeurosen 

der  oberen  Luftwege,  beziehungsweise  des  Ohres  vor  Militararzt.  Wien.  med. 

Wchnschr.,  1915,  No.  4,  p.  163. 
Menzel.     Symptom  des  sogenannten  labyrinthoren  Spontan-nystagmus.   Mili- 
tararzt. Wien.  med.  Wchnschr.,  1915,  v.  65,  p.  235. 
Meriel.     Deux  cas  de  tetanos  partiel.     Soc.  chir.,  2  Feb.,  1916. 
Merklen,  P.     Sur  les  determinations  psychiques  des  paratyphoides.     Rev.  Paris 

med.,  1916  (Part,  med.),  v.  19,  p.  96. 
Merklen.     Sur  les  determinations  psychiques  des  paratyphoides.     Paris  med., 

1916,  (Part.  Med.  I,  v.  21,  pp.  64-66. 
Merklen.     Sur  les  determinations  psychiques  des  paratyphoides.     Presse  med.. 

Par.,  1916,  v.  24,  p.  6. 
Merklen.     Note  sur  I'hypothermie  chez  les  militaires.     Bull,  et  mem.  soc.  med. 

d'hop.  de  Par.,  1917,  v.  33,  pp.  1008-1010. 
Merle    und    Schaidler.     Ausbildung    und    Berufstatigkeit    der    Kriegsblinden, 

Deutsche  med.  Wchnschr.,  Leipz.  u.  Berl.,  1916,  v.  42,  p.  468. 
Mesnard.     Tetanos  monoplegique.     Marseille  med..  Par.,  191 7,  pp.  363-365. 
Metcalfe,  F.     A  Red  Cross  "  Plattsburg";    the  U.  S.  Army  Ambulance  Corps' 

Camp  at  Allentown,  Pa.     Red  Cross  Mag.,  Wash.,   1917,  v.  12,  pp.  430- 

436. 
Meyer,  E.    Ps^'chosen  und  Neurosen  in  der  Armee  wahrend  des  Krieges.  Deutsche 

med.  Wchnschr.,  Berl.  u.  Leipz.,  1914,  v.  40-,  pp.  2085-2088. 
Meyer,  E.     L'eber  die  Frage  der  Dienstbeschadigung  bei  den  Psychosen.     Miin- 

chen.  med.  Wchnschr.,  1916,  Ixiii,  1558. 
Meyer,  E.     Der  Einfluss  des  Krieges,  insbesondere  des  Kriegsausbruch;  auf  schon 

bestehende  Psychosen.     Archiv.  f.  Psych.,  Berl.,  1915,  v.  55,  pp.  353-364. 
Meyer,  E.     Functionelle  Nervenstorungen  bei  Kriegsteilnehmen  nebst  Bemer- 

kungen  zur  traumatischen  Neurose.     Deutsche  med.  Wchnschr.,  Leipz.  u. 

Berl.,  1915,  v.  41,  pp.  1509-1511. 
Meyer,  E.     Beitrag  zur  Kenntnis  des  Einflusses  kriegerischer  Ereignisse  auf  die 

Entstehung  geistiger  Storungen  in  der  Zivilbevolkerung  und  zu  der  physi- 

schen  Infektion.      Ibid.,  Ivi,  247-279. 
Meyer,  E.     Zwei  Soldaten  mit  psychogenen  Storungen.     Berl.  klin.  Wchnschr., 

1915,  v.  52',  p.  94. 
Meyer,  E.     Die  Frage  der  Laminektomie  von  neurologischen  Standpunkt.     Berl. 

khn.  Wchnschr.,  1915,  v.  52',  pp.  282-283. 

med.  Wchnschr.,  1916,  No.  44,  p.  1558. 
Meyer,  E.     BemerkungenzuderDifferentialdiagnose  der  Psychosen.    Reaktionen 

mit  besonderer  Beriicksichtigung  der  im  Kriege  beobachteten  psychischen 

Storungen.     Archiv.  f.  Psychiat.  191 6,  v.  56,  pp.  244-246. 
Meyer,  E.     Kriegshysterie.     Deutsche  med.  Wchnschr.,  Leipz.  u.  Berl.,  1916,  v. 

42,  pp.  69-71. 
Meyer,  E.     Funktionelle  Ner\'enstorungen  bei  Kriegsteilnehmern  nebst  Bemerk- 

ungen  zur  traumatischen  Neurose.     Med.  Klin.,  Berl.,  1916,  v.  12,  p.  26. 
Meyer,  E.     Krankheitsanlagen   und   Krankheitsursachen   im   Gebiete  der   Psy- 
chosen und  Neurosen.     Berl.  klin.  Wchnschr.,  191 7,  No.  3,  Rev.  Cor.  bl.  f. 
Schweize  Arztr.,  191 7,  No.  19,  p.  620. 
Meyer,  E.     Ueber  die  Frage  der  Dienstbeschadigung  bei  den  Psychosen.  Arch.  f. 

Psychiat.,  Berl.,  1917,  57,  208-220. 
Meyer,  E.  und  Frida  Reichmann.     Uber  nervose  Folgezustande  nach  Granat- 
explosionen.     Arch.  f.  Psychiat.,  Berl.,  1916,  v.  56,  No.  3. 


BIBLIOGRAPHY 


953 


Mezie,  A.     Troubles  reflexes  et  insuffisance  cerebrale.     Gazette  hebdomadaire 

des  Sciences  medicales  de  Bordeaux,  23  Sept.  1916. 
Michon,  E.     Impotence  fonctionnelle  du  muscle  trapeze  a  la  suite  d'une  plaie  par 

balle  de  la  region  sus-claviculaire.     Bull,  et  mem.  soc.  de  chir.  de  Par.    1915 

V.  41,  pp.  652-655. 
Midelton,  W.  J.     Nerves  and  the  war.     Med.  Times,  Lond.,  1914,  v.  42,  pp.  726 

742,  758,  776,  786,  802,  835. 
Mignard.     Syndrome    psychique    atopique    chez    les    blesses    cranio-cerebraux 

(Observe  quelques  mois  apres  la  blessure).     Montpel.  med.,   1916,  v.  39, 

p.  65. 
Mignard.     Quelques    considerations    sur    la    responsabilite   des    blesses   cranio- 
cerebraux.     Montpel.  med.,  1916,  v.  39,  p.  127. 
Mignot,  Roger.     L'evolution  de  la  paralysie  generale  chez  les  officlers  combat- 

tants.     Presse  med.,  Par.,  1917,  v.  25,  pp.  487-488. 
Milian,  G.     Battle  hypnosis.     Med.  Press  and  Circ,  Lond.,  1915,  n.s.,  c,  486-488. 
Milian,  G.     Les  alienes  dans  I'armee.     Paris  med.,  1914-15,  v.  15,  (Part,  med.), 

p.  458. 
Milian,  G.     L'hypnose  des  batailles.     Paris  med.,  v.  15,  1914-15,  pp.  265-270. 
Milian,    G.     Desertion   ou   fugue.     Paris   med.,   (Part,  med.),   1915,  v.   17,  pp. 

_ 11-13- 
Milian,  G.     Les  eruptions  provoquees.     Paris  med.,  1917,  xxi,  343-351. 
Milian,  G.     La  fete  au  camp.      Paris  Med.,   1915,   (Part,    med.),   1915,  v.   17, 

pp.  11-13. 
Military  mental  cases.     Med.  officer,  Lond.,  1915,  v.  14,  p.  150. 
Military  orthopaedics  and  the  American  unit.     Brit.  M.  J.,  Lond.,  1917,  v.  i, 

p.  772. 
Military  Orthopedic   Surgery.     No.  4,  Medical  Manual  War  Series.     Lea  and 

Febiger,  191 8. 
Military  psychiatry.     Bos.  M.  and  S.  J.,  1918,  clxxviii,  98. 
Milligan,  E.  T.  C.     Medical  Experiences  in  the  War  Zone.     M.  J.  Australia, 

Sydney,  1917,  v.  i,  pp.  201-203. 
Milligan,  E.  T.  C.     Method  of  treatment  of  "  shell  shock."     Brit.  Med.  Jour., 

1916,  ii,  73. 

Milligan,  E.  C.     Treatment  of  Shell  Shock.     J.  Roy.  Army  Med.  Corps,  Lond., 

1917,  v.  28,  pp.  272-273. 

Milligan,  W.     Functional  Cases.     Discussion.     Proc.  Roy.  Soc.  Med.,  Lond., 

1914-1915,  (sect,  laryncol.),  v.  8,  p.  118. 
Milligan,  W.     Treatment  of  "  Functional  aphonia  "  in  Soldiers  from  the  Front. 

J.  Laryngol.,  Lond.,  191 6,  v.  31,  pp.  299-300. 
Milligan,  W.     Treatment  of  Shell  Shock.     Brit.  M.  J.,  Lond.,  1916,  ii,  p.  73; 

also  ii,  p.  242. 
Milligan  and  Westmacott.     Warfare  injuries  and  neuroses.     J.  Laryngol.,  191 5, 

v.  30,  p.  297. 
MUls,  A.   E.     Some   nerve   injuries  seen  on  active  service.     M.  J.  Australia, 

Sydney,  191 7,  v.  4,  pp.  73-75- 
Mills,  Lloyd.     Projectile  Wounds  of  the  Head.     J.  Am.  M.  Ass.,  Chicago,  1915, 

V.  65,  pp.  1424-1427.  _  ,    .     .  ,,  .      .,.. 

Mingazzini,  G.     Sindromi  nervose  organiche  consecutive  a  lesioni  (da  proiettili) 

del  cervello.  Policlin.,  Roma,  1916  (sez.  med),  v.  23,  p.  409. 
Mingazzini,  G.     Neurologia  di  guerra  (ferite  da  proiettile  del  cervello  e  midollo 

spinale).     Policlinico,  Roma,  sez.  prat.,  1917,  v.  24,  pp.  22-23. 
Mingazzini,   G.     Osservazioni  cliniche  sulle  lesioni  del  cervello  e  del   midollo 

spinale  da  proiettili  di  guerra.     Policlin.,  Roma,  1917.  v.  24  (sez.  med.),  pp. 

121,  178,  189. 
Mirallie,  M.     Paralysies  reflexes.     Rev.  gen.  de.  path,  de  guerre.  Par.,  1916,  No.  i, 

PP-    19-35-  ,        ,        r.  r  ■      ^ 

Mire,  J.     Folies  de  guerre  chez  les  civils.     Caducee,  Par.,  1916,  v.  16,  p.  141. 
Mire,   J.     Folies  de  guerre  chez  les  civils.     J.  de  med.  de  Par.,  1917,  v.  36, 

p.  12. 
Misch,  W.     Ueber  Hemiplegie  bei  Diphtherie.  Neurol.  Centralbl.,  Leipz.,  1916, 

V.  35,  No.  22. 
Mizie,  A.     Troubles  reflexes  et  insuffisance  cerebralles.     Gaz.  hebd.  d.  sc.  med., 

Par.,  1916,  V.  2,  pp.  141-142. 


954  BIBLIOGRAPHY 

Mohr,  F.  Behandlung  nervoser  und  depressiver  Zustandsbilder  bei  Kriegsteil- 
nehmer.  n.     Aerztl.  Centralbl.  Ztg.,  1915,  Wien,  v.  32,  p.  134. 

Mohr,  F.  Zur  Entstehung,  Vorhersage  und  Behandlung  nervoser  und  depres- 
siver Zustandsbilder  bei  Kriegsteilnehmern.  Med.  Klin.,  Berl.,  1915,  xi, 
920. 

Mohr,  F.     GrundsatzHches  zur  Kriegsneurosenfrage.  Med.  Klin.  Berl.  u.  Wien, 

1916,  V.  12,  pp.  89-93.     Rev.  Aerztl.  Rundschau,  1916,  v.  26,  pp.  40-41. 
Mohr,  F.     Behandlung  der  Kriegsneurosen.     Therap.  Monatschr.,   Bed.,  1916, 

V.  30,  No.  3. 
Molhaut,  M.     Les  troubles  moteurs  d'ordre  reflexe.     Arch,  med.,  Beiges,  Brux, 

1917,  V.  47,  pp.  910-927. 

Moll,    A.     Ueber    psychopathologische    Erfahrungen    vom    westlichen    Knegs- 

schauplatz.     Berl.  klin.  Wchnschr.,  1915,  iii,  95. 
Moll,  A.     Kriegsarztlicher  Abend,  Berlin,  Jan.   12,  1915.     Psych iat.-Neurolog. 

Wchnschr.,  Halle,  a.  s.,  1914-15,  v.  16,  p.  402. 
Moll,  A.     Psychopathologische  Erfahrungen  vom  westlichen  Kriegsschauplatz. 

Med.  Klin.,  Berl.  u.  Wien,  1915,  v.  ii^,  p.  710. 
Moll,  A     Psychopathologische   Erfahrungen  vom  westlichen   Kriegsschauplatz. 

Ztschr.  f.  artzl.  Fortbild.,  1915,  No.  10,  pp.  305-310;  also  No.  9,  pp.  261-266. 
Moll,  A.     Psychopathologische  Erfahrungen  im  Kriege.     Aerzt.  Central.  Zeit., 

Wien,  1915,  V.  27,  p.  139. 
Moll,   A.     Psychopathologische  Erfahrungen  auf  dem  westlichen  Kriegsschau- 
platz.    Berl.  klin.  Wchsnchr.,  1915,  No.  4,  p.  95. 
Mollison,  W.  M.     Cases  of  deafness  as  a  result  of  the  war.     Guy's  Hosp.  Gaz., 

Lond.,  1916,  Feb.,  pp.  69-71. 
Monbrun,  A.     Les  hemianopsies  en  quadrant  et  le  centre  cortical  de  la  vision. 

Presse  med..  Par.,  1917,  v.  25,  pp.  607-609. 
Monier-Vinard.     Troubles  physiopathiques  medullaires  post-tetaniques  et  latents 

deceles  par  I'anesthesie  chloroformique.     Rev.  neurol.  Par.,  1917,  v.  24,  pp. 

568-572. 
Montier.     Discussion  de  la  conduite  a  tenir  vis-i-vis  des  blessures  du  crane  —  par 

P.  Marie.     Rev.  neuro'..  Par.,  1916,  v.  29,  p.  469. 
Moravensic,  von  E.  C.     Die  Rolle  des  Krieges  im  der  Aetiologie  nervoser  insbeson- 

ders  psychische  Storungen.     Neurol.  Centralbl.,  Leipz.,  191 5,  v.  34,  p.  637. 
Moravskaya,  V.  Ye.  and  Moravskaya,  Yu.  A.     (The  "  Kokhanuvka  "  institution 

for  the  insane  and  the  war).     Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp._3i  1-333- 
Morax,   V.     Notes   cliniques  et   statistiques   sur  I'ophtalmie  sympathique   aux 

armees.     Ann.  d'ocul.,  Par.,  1917,  v.  144,  pp.  706-722. 
Morchen.     Traumatische    Neurosen     und     Kriegsgefangene.     Miinchen.    med. 

Wchnschr.,  1916,  v.  64,  No.  32. 
Morestin.     Mutisme  hysterique  a  I'occasion  d'une  blessure  de  la  langue.      J.  de 

med.  et  de  chir.,  1915,  Jan.,  v.  86. 
Morestin.     Un  cas  de   mutisme  hysterique  a   I'occasion  d'une  blessure   de  la 

langue.     Bull,  et  mem.  soc.  de  chir.  de  Par.,  1915,  v.  41,  pp.  98-100. 
Morhardt,  P.  E.     Cure  de  soleil  et  chirurgie  de  guerre.     Paris  med.,  191 5-16, 

V.  17,  pp.  315-317-  

Moricand,  I.     Note  sur  un  cas  de  paralysie  radiale  bilaterale  par  compression, 

due  k  I'usage  prolonge  des  bequilles  chez  un  soldat  atteint  de  monoplegie 

crurale  hysterique.     Societe  de  Neurol.,  1915. 
Mor«elli,  Arturo.     (Psychiatry  of  War.)     Boll.  d.  r.  Accad.  med.  di  Genova, 

1916,  V.  31,  p.  65. 

Morselli,  A.  Sui  fenomeni  fisio-patologici  da  emozione  massime  m  rapporto 
alia  neurologia  di  guerra.  Quaderni  di  psichiat.,  Genova,  1916,  v.  3,  pp. 
206-214. 

Morselli,  A.  Sugli  stati  confusionali  psichici  da  guerra.  Quaderna  di  psichiat., 
Genova,  191 7,  iv,  45-52. 

Morselli,  A.     Sopra  le  sindromi  emotive  di  guerra.     Rev.  di  patol.  nerv.,  Firenze, 

191 7,  V.  22,  pp.  329-336. 

Mosny,  E.  La  reeducation  professionelle  et  la  readaptation  au  travail.  Ann. 
d'Hyg.,  Par.,  1915.  v.  23,  pp.  317-339- 

Mosquet,  P.  et  Schwartz,  Anselme.  The  immediate  treatment  of  head  in- 
juries from  projectiles.  J.  Roy.  Army  Med.  Corps,  Lond.,  1916-,  v.  26, 
pp.  278-283. 


BIBLIOGRAPHY  955 

Mott,  F.  W.     The  microscopic  examination  of  the  brains  of  two  men  dead  of 

commotio  cerebri  (shell  shock)  without  visible  external  injury,     Ibid.,  612- 

615,  I  pi. 
Mott,  F.  W.     Psychic  mechanism  of  the  voice  in   relation  to  the  emotions. 

Brit.  M.  J.  Lond.,  1915,  ii,  pp.  845-847. 
Mott,  F.  W.     Discussion  on  shell  shock  without  visible  signs  of  injury.     Proc. 

Roy.  Soc.  Med.  Lond.,  1915-16,  v.  9  (sec.  psychiat.  and  neurol.),  pp.  1-44. 
Mott,  F.  W.     The  effects  of  high  explosives  upon  the  central  nervous  system. 

Tr.  M.  Soc.  Lond.,  1915-16,  xxxix,  157-226,  11  pi.     Also  Lancet,  Lond., 

1916,  i,  331.  545. 
Mott,  F.  W.     The  Lettsomian  lectures  on  the  effects  of  high  explosives  upon 

the  central  nervous  system.     Lancet,  Lond.,  191 6,  i,  v.  190,  pp.  331-338, 

pp.  441-449,    pp.  545-553;   also  Tr.  Med.  Soc.  Lond.,  1915-16,  v.  39,  pp! 

157-226. 
Mott,  F.  W.     Mental   hygiene  in  shell  shock.     J.  M.  Sc,  Lond.,  1917,  v.  63, 

pp.  467-488. 
Mott,    F.    W,     I.    On    war    psychoneurosis.      2.    The    psychology    of    soldiers' 

dreams.     Lancet,  Lond.,  1918,  i,  pp.  169-177. 
Mott,  F.  W.     Punctiform  hemorrhages  of  the  brain  in  gas  poisoning.     Brit.  Med, 

Jour.,  1917,  i,  637. 
Mott,  F.  W.     The  Chadwick  Lectures  on  mental  hygiene  and  shell  shock  during 

and  after  the  war.     Brit.  M.  J.,  Lond.,  1917,  ii,  39-42. 
Mott,  F,  W.     War  psychoneurosis.     Lancet,  Lon.,  1918,  i,  127,  177. 
Mougeot,  A.  and  Duverger.     Bradycardie  et  reflexe  oculocardiaque  dans  les 

traumatismes  oculaires,  crSniens,  encephaliques.     Presse  med..  Par.,  1917, 

V.  25,  pp.  730-732. 
Moure,  E.  J.     Paralysies  faciales  de  la  guerre.     Presse  med.,  Par.,  1916,  v.  24, 

pp.  161-164. 
Moure  et  Pietri.     L'organe  de  I'audition  pendant  la  guerre.     Arch,  de  med.  et 

de  pharm.  mil.,  Par.,  1916-,  v.  65,  pp.  809-837;  and  1916,  v.  66,  pp.  167- 

186. 
Mouriquand.     Sur  quelques  maladies  simulees.     Vomissements  pseudoporraces. 

Lyon  med.,  1917,  v.  126,  pp.  276-278. 
Moutier,  Francois.     Recherches  sur  les  troubles  labyrinthiques  chez  les  commo- 

tionnes  et  blesses  du  crane.     Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  9-15. 
Moynihan,  Berkley.     On  injuries  to  the  peripheral  nerves  and  their  treatment. 

Brit.  M.  J.,  1917,  ii,  pp.  571-574- 
Moynihan,  Berkley.    Injuries  to  the  peripheral  nerves  and  their  treatment.    Brit. 

Med.  Jour.,  1917,  ii,  571. 
Muenzer,  Arthur.     Die  Psyche  des  Verwundeten.      Berl.  klin.  Wchnschr.,  1915, 

V.  52,  pp.  234-235. 
Muirhead,  I.  B.     Shock  and  the  soldier.     Lancet,  Lond.,  1916,  i,  p.  1021. 
Miiller.     Typhuspsychose.     Deutsche  med.  Wchnschr.,    191 5,   Berl.  u.  Leipz., 

V.  41,  pp.  331-332. 
Myerhof,  M.     Night-blindness  as  a  war  disease.     Am.   J.   Ophth.,  St.   Louis, 

1916,  p.  139. 
Myers,  Charles  S.     Contributions  to  the  study  of  shell  shock.     Lancet,  Lon., 

1916,  ii,  461. 
Myers,  Charles  S.     Shell  shock.     Three  cases  of  loss  of  memory,  vision,  smell 

and  taste.     Lancet,  Lond.,  1915,  i,  pp.  316-320. 
Myers,    Charles    S.     Shell   shock.     An   account   of   certain   cases   treated   by 

hypnosis.     Lancet,  Lond.,   1916,  i,  pp.  65-69;    also  J.   Roy.  Army  Med. 

Corps,  Lond.,  1916,  v.  26,  pp.  642-655. 
Myers,   Charles   S.     Shell  shock.     Certain  disorders  of  cutaneous  sensibility. 

Lancet,   Lond.,  1916,  i,  pp.  608;    also  J.  Roy.  Army  Med.  Corps,  Lond., 

1916,  V.  26,  pp.  782-797. 
Myers,  Charles  S.     Shell  shock.     Certain  disorders  of  speech,  —  their  causation 
*  and  their  relation  to  malingering.     Lancet,  Lond.,   1916,  ii,  pp.  461-467; 

also  J.  Roy.  Army  Med.  Corps,  Lond.,  1916,  v.  27,  pp.  561-582. 
Ifaccarati,  Sante.     Medical  organization  of  the  Italian  army;    the  neuropsy- 

chiatric  service.     Jour.  A.  M.  A.,  1918,  Ixxi,  1477. 
NSgeli,  O.     Ueber  die  Entschadigung  der  Kriegsneurosen.      Med.  Cor.-Bl.  d. 

wiirtemb.  arztl.  Landesver.,  Stuttg.,  1916,  v.  86,  No.  5. 


956 


BIBLIOGRAPHY 


Nageli,  O.  Zur  Frage  der  traumatischen  Kriegsneurosen  im  besonderer  Beruck- 
sichtigung  der  Oppenheim'schen  Auffassungen.     Neurol.  Centralbl.,  Leipz., 

1916,  V.  35,  No.  12. 

Nageli,  O.     Schlussfolgerungen  fiir  die  Art  der  Abfindung  der  Kriegsneurosen. 

Ztschr.  f.  arztl.  Fortbldg.,  Nr.  8,  1918. 
Nageotte,  J.     Le  processus  de  la  cicatrisation  des  nerfs.     Rev.  Neurol.,  July,  1915. 
Nash,  E.  H.     Education  of  the  left  hand  of  disabled  sailors  and  soldiers.     Lancet, 

Lond.,  1917,  V.  I,  p.  964. 
Natalelli  and  Roger,  H.     Erythemes  de  la  face  provoques  pour  simuler  un  erysi- 

pele.     Arch,  de  med.  et  pharm.  mil.,  Par.,  1916-17,  Ixvi,  547. 
Naville,  F.     Le  traitement  et  la  guerison  des  psychonevroses  de  guerre  inveteres 

a  I'hopital  Saint-Andre  de  Salins.     Corr.-Bl.  f.  Schweizer  Aerzte,  Nr.  25, 

1918. 
Necessite  de  creer  des  etablissements  speciaiix  destines  aux  invalides  nerveux. 

Rev.  neurol.  Par.,  1916,  v.  23,  pp.  593-594- 
Necessite  des  services  de  psychiatrie  et  de  medecine  legale  airx  annees.  Caducee, 

Par.,  191 6,  v.  16,  pp.  43-45- 
Necessite  de  traiter  les  plicatiires  vertebrales  (camptocormies)  dans  les  centres 

neurologique  .     Rev.  Neurol.  Par.,  1917,  v.  24,  p.  137. 
Negro,  C.     Annotazione  di  neurologia  di  guerra.     Gior.  d.  r.  Accad.  di  med.  di 

Torino,  1916,  v.  22,  pp.  377-3^9- 
Neidiag,  M.  N.     (Ner\'Ous  phenomena  accompanying  poisoning  by  asphyxiating 

gases).      Russk.  Vrach.,  Petrogr.,  1917,  v.  16,  p.  397. 
Neilson,  W.  A.     The  Training  School  of  Psychiatric  Social  Work  at  Smith  College. 

I.    Educational  Significance  of  the  Course.     Mental  Hygiene,  II,  October, 

1918- 

Nepper  et  Vallee.  Recherches  comparatives  sur  les  impotences  fonctionnelles 
dues  aux  lesions  osseuses  et  articulaires  (ankyloses  et  resections)  du  membra 
superieur.     Paris  med.,  1916  (Part,  med.),  v.  21,  pp.  86-92. 

Neri,  V.     Moyen  pour  decouvrir  la  simulation  de  la  sciatique.     Presse  med..  Par., 

1917,  V.  25,  p.  64. 

Neri,  V.     Les  petits  signes  electriques  de  la  sciatique.     Presse  med.,  Par.,  191 7, 

V.  25,  pp.  466-468. 
Nervose  Disposition.     Med.  Cor.  Bl.  d.  Wiirttemb.  arztl.  Landesver.,  Stuttg., 

1916,  V.  86,  p.  42. 
Nervous  and  mental  disease  among  soldiers.     N.  Y.  Med.  Jour.,  1917,  cvi,  1043. 
Nervous  temperament  in  war.     Brit.  Med.  Jour.,  1918,  i,  649. 
Netter,  F.     L'  epilepsie  generalisee  consecutive  aux  traumatismes  de  guerre  crSnio- 

cerebraux.     Theses  de  Paris.     191 7-8,  No.  9. 
Neimiann,   E.     Psychologische   Beobachtungen  im  Felde.     Neurol.   Centralbl., 

1914,  V.  33,  pp.  1243-1245.  _ 

Neurasthenia  and  shell  shock.    Lancet,  Lond.,  1916,  1,  p.  627. 
Neurolog  e  de  Guerre.     Presse  Med.,  Par.,  1917,  v.  25,  pp.  217-221. 
Neutra,  W.     Einige  Bemerkungen  iiber  die   Beurteilung   und    Behandlung  der 

Kriegsneurosen.     Wien.  klin.  Wchnschr.,  1916,  v.  29,  p.  1253. 
Neutra,  W.     Wien.  klin.  Wchnschr.,  1917,  30,  1 198-9. 
Nevrite  irradiante  et  paralysies  ou  contractures  d'ordre  reflexe.     Rev.  gen.  de 

clin.  et  de  therap.,  Par.,  1916,  v.  30,  pp.  457-460. 
Nicolai,  George  F.     Biology  of  War.     Century  Co.,  1918. 
Niessl    von    Mayendorf.     Ueber    pathologische    Zitterformen    zur    Kriegszeit. 

Miinch.  med.  Wchnschr.,  1916,  v.  63,  p.  323. 
NiMtina-Pakhorzkaya,  T.  P.     (Case  of  choreo-athetosis  of  war-traumatic  origin). 

J.|Nevropat.  i  Psikhiat  .  .  .  Korsakova,  Mosk.,  1915-16,  v.  15,  pp.  436- 

444. 
Nissl.     Ueber  den  Stand  der  Hysterielehre  mit  besonderer  Beriicksichtigung  der 

Kriegserfahrungen.     Berl.  klin.  Wchnschr.,  1916,  v.  53,  p.  232. 
Noehte.     Nystagmus   bei   Verletzungen    des   Fusses   der   II.  Stirnhirnwindung. 

Deut.  Med.  Woch.,  1915,  xli,  1217. 
Noica,   (de  Bucarest.)     Sur  la  contracture  dans  les  paraplegics  spasmodiques. 

Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  257-263. 
Nonne,   M.     Soil  man   wieder   "  traumatische   Neurose  "   bei   Kriegsverletzten 

diagnostizieren?     Med.  Klin.,  Berl.  u.  Wien,  1915,  v.  II^  pp.  849-854;  also 

pp. 948-949- 


BIBLIOGRAPHY  957 

Nonne,  M._    Zur  therapeutischen  Venvendung  der  H>-pnose  bei  Fallen  von  Kriegs- 

hysterie.     Med.  Klin.,  Berl.  u.  Wien,  1915,  v.  11-,  pp.  1391-1396. 
Nonne,   M.     Falle  von   Kriegsvenvundeten.     Xeurol.    Centralbl.,    191 5,   v.   34, 

pp.  41-46. 
Nonne,  M.     Demonstration  von  Nervenkriegsverletzungen.     Neurol.  Centralbl., 

Leipz.,  1915,  V.  34,  pp.  317-321. 
Nonne,  M.     Ueber  Xeurosen  und  Hysterle  bei  Soldaten.     Neurol.  Centralbl., 

Leipz.,  1915,  V.  34,  pp.  408-409. 
Nonne,  M.     Kriegsverletzungen.     Ztschr.  f.  d.  ges.  Neurol,  u.  Psychiat.,  Berl.  u. 

Leipz.,  1914-15,  V.  II,  pp.  198-200. 
Nonne_,  M.     Ueber  Polyneuritis  gemischter  Xer\-en  bei  neurasthenischen  Kriegs- 

teilnehmern.     Deutsche  Ztschr.  f.  Nervenh.,  Leipz.,  1915,  v.  53,  pp.  464-469. 
Nonne,  M.     Hysterie  bei  Soldaten.     Ztschr.  f.  d.  ges.  Neurol,  u.  Psychiat.,  Berl. 

u.  Leipz.,  1914-15,  V.  II,  pp.  421-422. 
Nonne, _M.     Zur  therapeutischen  Werth  der  Hypnose  bei  Fallen  im  Kriegshys- 

terie.     rvliinchen.  med.  Wchnschr.,  1915,  v.  62,  p.  1579. 
Nonne,    M.     Xen-enverletzungen   und    Erkrankungen   im    Kriege.     (Abstract). 

Deutsche  med.  Wchnschr.,  Berl.,  u.  Leipz.,  1915,  v.  41,  pp.  573-574. 
Nonne,    M.     Nervenkriegsverletzungen.     Deutsche   med.    Wchnschr.,    Berl.    u. 

Leipz.,  1915,  V.  41,  p.  695. 
Nonne,  M.     Hypnose  bei  Kriegshysterie.     Deutsche  med.  Wchnschr.,  Berl.  u. 

Leipz.,  1915,  V.  412,  pp.  1587-1588. 
Nordman,   Charles.      Psychose  post-typhique  chez  un  adulte  avec  evolution 

probable  vers  la  demence  precoce.     Ann.  med.-psychol..  Par.,  1916-17,  v.  7, 

PP-  493-498. 
Nordmann  et  Bonhomme.     De  I'utilisation  des  indisciplines  en  temps  de  guerre. 

Ann.  med.  psychol.,  Par.,  1916-17,  v.  32,  pp.  490-493;   also  pp.  519—524. 
Norman,  Hubert  J.     Some  neuroses  of  the  war.     Rev.  of  Clark.,  J.  ^lent.  Sc, 

Lond.,  1917,  V.  63,  pp.  119-121. 
Notes  on  British  miUtary  medical  arrangements;    \vork  in  the  restoration  and 

reeducation  of  disabled  soldiers;   treatment  of  cases  of  heart  disease;    mili- 
tary orthopedic  hospitals.     Mod.  Hosp.,  St.  Louis,  1917,  v.  9,  p.  293. 
Notes  on  hydrological  treatment  for  wounded  soldiers  and  sailors;     with  a  list 

of  the  British  spas  and  health  resorts  and  the  disorders  which  they  benefit. 

Lond.,  1915,  Adlard  and  Son,  20,  p.  9. 
Nouvelle  Jeanne  d'Arc.     Ann.  med.  psychol.,  Par.,  1914-1915,  p.  422. 
Nuthall,  A.  W.     Three  cases  of  gunshot  wound  of  the  superior  longitudinal  sinus. 

J.  Roy.  Army  Med.  Corps,  Lond.,  1916,  v.  26,  pp.  235-240. 
Nunneley,  P.  P.     Treatment  by  physical  methods  of  mental  disabilities  induced 

by  the  war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10  (Sect.  Balneol.), 

PP-  3<>-34-  .  .  ,  .,  ,       . 

Nyns,  Adrien.     La  reeducation  professionnelle  d'apres  les  varietes  d'lmpotence. 

Paris  med.,  1916,  v.  21,  pp.  493-496. 
Obendorf,  C.  P.     Traumatic  hysteria.     N.  Y.  Med.  Jour.,  1917,  c^-i,  874. 
Oloff.     Bemerkenswerte  Falle  von  \'erft'undung  des  Sehorgans.     Deutsche  m.ed. 

Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41^,  pp.  1190-1192. 
O'Malley,  J.  F.     Functional  aphonia.     Proc.  Roy.  Soc.  Med.,  Lond.,  1914-15, 

V.  8  (Sect.  Laryng.),  p.  116. 
O'Malley,  J.  F.     Warfare  neuroses  of  the  throat  and  ear.     Lancet,  Lond.,  19 16, 

i,  1080. 
Ombredanne,  L.  and  Ledovtx-Lebard,  R.      Localisation  et  extraction  des  pro- 
jectiles.    1917,  Paris,  Masson  et  Cie. 
Oppenheim,  H.     Zur  Kriegsneurologie.     Berl.  klin.  Wchnschr.,   19 14,  No.  48, 

pp.  1853-1856.  ,  ,     .        -^.         . 

Oppenheim,    H.     Krankendemonstrationen    zur    Kriegsneurologie.     Discussion 

Rothmann-Cohn,  Toby.     Berl.  klin.  Wchnschr.,  191 5,  v.  42^,  p.  168. 
Oppenheim,    H.     Der    Krieg    und    die    traumatischen    Neurosen.     Berl.    klin. 

Wchnschr.,  1915,  v.  52,  pp.  257-261. 
Oppenheim,  H.     Kriegsneurosen.     Med.  Klin.,  Berl.  u.  \\ien.   1915,  v.   11,  p. 

Oppenheim,  H.  Bemerkung  zu  dem  Aufsatze  Nonnes:  Soil  man  wieder  trau- 
matische  Neurose  bei  Kriegsverletzten  diagnostizieren?  Med.  Klin.,  Berl. 
u.  Wien,  191 5,  v.  ii=,  pp.  920-921. 


958  BIBLIOGRAPHY 

Oppenheim,  H.     Ueber  Hemiplegia  spinalis  mit  homolateraler  Hemianasthesie. 

Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  49-51- 
Oppenheim,  H.     Zur  traumatischen  Neurosen  im  Kriege.     Neurol.  Centralbl., 

Leipz.,  1915,  V.  34,  pp.  514-518. 
Oppenheim,  H.     Die  Neurosen  nach  Kriegsverletzungen.     Neurol.  Centralbl., 

Leipz.,  1915,  V.  34,  pp.  810-813. 
Oppenheim,  H.     Der  Krieg  und  die  traumatischen  Neurosen.     1915,   Berlin,  A. 

Herschwald. 
Oppenheim,  H.     Ueber  Kriegsverletzungen  des  peripheren  und  zentralen  Ner- 

vensystems.     Ztschr.  f.  arztl.  Fortbild.,  Jena,  1915,  No.  4,  pp.  97-106. 
Oppenheim,  H.     (Discussion  of  Lewandowsky)   Ueber  Kriegsverletzungen  des 

Nervensystems.     Deutsche  med.  Wchnschr.,  1915,  v.  411,  p.  89. 
Oppenheim,    H.      (Further    discussion)    Ueber    die   traumatischen    Neurosen. 

Neurol.  Centralbl.,  Leipz.,  1916,  v.  35,  No.  13. 
Oppenheim,    H.     "  AUoparalgie."     Neurol.    Centralbl.,    Leipz.,    191 6,    No.    21. 

Rev.  Berl.  klin.  Wchnschr.,  1916,  No.  48,  p.  1302. 
Oppenheim,    H.     Zur    Frage    der    traumatischen    Neurosen.     Deutsche    med. 

Wchnschr.,  Leipz.  u.  Berl.,  1916,  v.  42,  pp.  1 567-1 570. 
Oppenheim,  H.     Die  Neurosen  infolge  von  Kriegsverletzungen.     1916,  Berlin, 

S.  Karger. 
Oppenheim,   H.     (Aussprache  zum  Vortrag  von  Singer:    Zitterer  im   Felde.) 

Neurol.  Centralbl.,  37,  Nr.  12,  1918. 
Oppenheim,  Nonne,  Gaupp,  etc.     Neurosen  nach  Kriegsschadigungen.     Miinch. 

med.  Wchnschr.,  1916,  No.  45,  p.  1594. 
Oppenheim,  R.     L'amnesie  traumatique  chez  les  blesses.     Progres  med..  Par., 

1917,  3.  s.,  xxxii,  189,  199. 
Oppeiiieim,  R.     Le  pouls,  la  tension  arterielle  et  le  reflexe  oculocardiaque  dans 

les  suites  eloignees  des  traumatismes  craniens.     Progres  med..  Par.,  191 7, 

No.  7,  PP-  53-55- 
Oppenheim,  R.  et  Hallez,  G.  L.     La  diplegie  faciale  traumatique.     Paris  med., 

1917,  V.  23,  pp.  136-139- 
Organic  lesions  in  shell  shock.     Bos.  Med.  and  Surg.  Jour.,  19 18,  24. 
Organisation  des  asiles  pubUcs  d'aUenes  de  la  Seine  apres  la  guerre.     Progres 

med..  Par.,  1917,  v.  32,  p.  366. 
Ormond,  A.  W.     Short  notes  on  30  cases  of  blinded  soldiers  during  the  present 

war.     Guy's  Hos.  Gaz.,  Lond.,  1915,  May  22. 
Ormond,   A.   "W.     Treatment   of   "  concussion   blindness."     Guy's   Hos.   Gaz., 

Lond.,  1915,  V.  30,  pp.  99-101. 
Ormond,  A.  W.     Treatment  of  "  concussion  blindness."     J.  Roy.  Army  Med. 

Corps,  Lond.,  191 6,  v.  26,  pp.  43-49. 
Orth.     Simulation.     Dementia  Praecox.     Deutsche  med.   Wchnschr.,   1915,  v. 

412,  p.  936. 
Osier,   Sir  WilUam.      Science   and  war.      1915,   Oxford,   Clarendon  Press,   40 

p.,  8°. 
Osnos.     (Case  of  nervous  and  mental  disease  during  the  war.)     Nevropat.  1. 

Psikhiat.,  Korsakova,  Mosk.,  1915-16,  v.  15,  p.  143. 
Oudet,  L.     Deux  epreuves  pratiques  pour  depister  les  simulateurs  de  surdite. 

Presse  med.,  Par.,  1917,  xxv,  annexes,  515. 
Overbeck-Wright,  A.  W.     A  case  of  malingering.     Indian  M.  Gaz.,  Calcutta. 

1915,  V.  50,  p.  334. 
Overbeek,  H.  J.     Psychoses  in  war  and  wounds  of  the  nervous  system.     Mil.- 

geneesk  Tijdschr.,  Haarlem,  1915,  xix,  209-216. 
Overbeek,    H.    J.     ^Iobilisatie-neu^osen    en    Psychosen.     Nedrl.    Tijdschr.    v. 

Geneesk.,  Amst.,  1917,  v.  i,  pp.  1617-1620. 
Pachantoni,  D.     Paralysies  multiples  des  nerfs  craniens  par   "  vent  d'obus." 

Rev.  med.  de  la  Suisse  Rom.,  Geneve,  191 7,  v.  37,  pp.  226-229. 
Pactet,  M.     La  reforme  des  paral>^iques  generaux.     J.  de  med.  de  Bordeaux, 

1917,  V.  88,  pp.  163-164. 
Pactet  et  Bonhomme.     Deux  observations  de  peur  invincible  chez  des  combat- 

tants.     Ann.  med.  psychol.,  Par.,  191 7,  v.  73,  pp.  375-380. 
Padovani,  E.     Note  e  osser\'azioni  dalle  zone  di  guerra.     Rassegna  di  studi 

psichiat.,  Siena,  1915,  v.  5,  pp.  342-346. 


BIBLIOGRAPHV  959 

Pangon,  J.  et  Gate,  J.     Accidents  syphilitiques  et  dermatoses  simules.     Lyon 

med.,  1916,  V.  125,  pp.  216-219. 
Pansky.     Contribution  i  I'etude  de  la  psychonevrose  consecutive  a  la  contusion 

et  aux  incidents  d-es  combats.      Nouvelles  medicales  de  Minsk,  No.  3,  1915. 
Pansky.     Contribution  a  la  connaissance  des  nevros.js  de  contusion  compliquees 

par  des  lesions  organiques  du  systeme  ners^eux.     Gazette   medicale   russe, 

No.  9,  1915. 
Parhon,  C.  J.  et  Vasiliu,  Mme.  Eug.     Troubles  sensitifs  et   moteurs  (tremble- 

ment  k  type  parkinsonien;  phenomenes  paral>tiques)   a  topographie  sur- 

tout  cubitale,  du  cote  droit,  a  la  suite  d'une  lesion  cranienne  dans  la  region 

pari  tale  gauche.     Rev.  Neurol.,  Par.,  1917,  v.  24,  pp.  156-162. 
Parkiason.     An  inquiry  into  the  cardiac  disabilities  in  soldiers  on  active  service. 

Lancet,  Lond.,  1916,  ii,  pp.  133-138. 
Parkiason,    J.     Digitalis   in   soldiers   with   cardiac   symptoms   and   a   frequent 

pulse.     Heart,  191 7,  vi,  321. 
Parkinson,  J.  and  Drury,  A.  N.     P-R  interval  before  and  after  exercise  in  cases 

of  "  soldier's  heart."     Heart,  1917,  vi,  337. 
Parkinson,  J.     Pulse  rate  on  standing  and  on  slight  exertion  in  healthy  men 

and  in  cases  of  "  soldier's  heart." 
Parkinson,  J.  and  Koefod,  H.     Immediate  effect  of  cigarette  smoking  on  healthy 

men  and  on  cases  of  "  soldier's  heart."     Lancet,  Lon.,  1917,  ii,  232. 
Paris.     Alienation  mentale  et  etat  de  guerre,  leurs  rapports.     Societe  d«  medecine 

de  Nancy,  191 5. 
Pariset.     Le  massage  chirurgical,  method     d'enseignement  rapide  a  I'usage  de 

infirmiers  militaires.     Presse  med..  Par.,  1915,  v.  23,  pp.  97-100. 
Parsons,  J.  H.     The  psychology  of  traumatic  amblyopia  following  explosions 

of  shell.     Proc.  Roy.  Soc.  j\Ied.,  Lond.,  1914-15,  v.  8,   (neurol.  sect.),  pp. 

55-68;   also  Lancet,  Lond.,  1915,  i,  p.  697. 
Pascha,  Wieting.     Leitsatze  der  funktionellen  Nachbehandlung  kriegschirurgischer 

Schaden.     Samml.  klin.  Vortr.  n.  F.,  Leipz.,  1915,  pp.  123-165. 
Pastini,    C.     Commozione   dei   centri   nerv'osi   da   esplosione   violenta   a   breve 

distanza.     (Influenza  del  delore  finio  sullo  stato  psichico).     Riv.  di  patol. 

neu.,  Firenze,  1916,  v.  21,  pp.  433-438. 
Paton,  Stewart.     Mobilizing  the  brains  of  the  nation.     Mental  Hyg.,  Concord, 

N.  H.,  v.  I,  pp.  334-344- 
Paton,  Stewart.     Effects  of  low  oxygen  pressure  on  the  personality  of  the  avi- 
ator.    Jour.  A.  M.  A.,  1918,  Ixxi,  1399. 
Paton,  Stewart,  MacLake,  William,  Hamilton,  Arthur  S.     Personality  Studies 

and  the  Personal  Equation  of  the  Aviator.      Mental  Hygiene,  II,  October, 

1918. 
Paul,    B.      Beobachtungen    iiber    Nachtblindheit    im    Felde.    Miinchen    med. 

Wchnschr.,  1915,  v.  62,  pp.  1 548-1 550. 
Paul,  B.     Zur  Therapie  der  Nachtblindheit.     Rev.  Miinchen  med.  Wchnschr., 

1915,  V.  622,  p.  1707. 
Paulian,   Demetre.      Hemiparaplegie  fonctionnelle  gauche  avec  troubles  de  la 

sensibilite   et   abolition   du    reflexe   cutane   plantaire.     Rev.  neurol.,  Par., 

1914-15,  v.  222,  pp.  431-433.  _ 
Paulian.     Sur  quelques  cas  d'hemiplegie  cerebelleuse.     Rev.  neurol..  Par.,  1916, 

v.  23,  pp.  18-20. 
Payne,  Charles  R.  and  Jellifie,  S.  E.     War  neuroses  and  psychoneuroses.     Jour. 

Nerv.  and  Ment.  Dis.,  1918,  xlviii,  246,  325. 
Pegler,  L.  H.     Case  of  ner\^ous  or  functional  aphonia.     Proc.  Roy.  Soc.  Med., 

Lond.,  1915-16,  v.  9  (sec.  Laryngol.),  pp.  1 18-120. 
Pelissier,   A.    et   Borel,   P.     Hemiplegie  spinale  avec   troubles  de  la  sensibilite 

homolateraux.     Rev.  neurol..  Par.,  1914-15,  v.  22^,  pp.  125-127. 
Pellacani,    Guiseppe.     Sulla  nosografia  di   alcune   neuropatie  caratterizzati  da 

sindromi  accessuali  epilettoidi.     Riv.  di  patol.  nerv.,  Firenze,  1917,  v.  22, 

pp.  131-172. 
Pelz.     Ueber  hysterische  Aphonen.     (Arch.  f.  Psych.,  1916,  v;  57,  No.  2,     pp. 

445-465.)     Rev.  Berl.  klin.  Wchnschr.,  1916,  No.  6,  p.  434. 
Pemberton,  Hugh  S.     The  psychology  of  traumatic  amblyopia  followmg  the 

explosion  of  shells.     Lancet,  Lond.,  191 5i  i.  P-  967- 


960 


BIBLIOGRAPHY 


Penhallow,  Dunlap  P.     Mutism  and  deafness  due  to  emotional  shock  and  ether- 
ization.     Boston  M.  and  S.  J.,  1916,  174,  p.  131 1. 
Penhallow,  Dunlap  P.     Military  surgery.     1916,  London,  Henry  Frowde,  pp. 

367-39^'^- 
Pensions  for  Mentally  Incapacitated.     Brit.  M.  J.,  Lond.,  19 15,  i,  p.  820. 
Perls,  W.     Beitrag  zur  Symptomatologie  und  Therapie  der  Schadelschiisse  (Nach 

Beobachtungen   in   den   Heimatlazaretten).     Bruns'    Kriegschir.     Hefte   d. 

Beitr.  z.  Klin.  Chir.,  Tubing,  1917,  105,  435. 
Peterson,  Joseph  and  David,  Quentin  J.     The  psychology  of  handling  men  in 

the  army.     Ferine  Book  Co.,  1918. 
Pfersdorff.     Ueber  paranoide  Erkrankungen  im  Felde,  Neurol.  Centralbl.     Nr. 

16,  1918. 
Pflugradt,  R.     Ueber  Schadeldefekte.     Ein  Beitrag  zur  Behandlung  der  Schadel- 
schiisse in  den  Heimatlazaretten.     Bruns'  Kriegschir.     Hefte  d. 
Pforringer.     Psychische  Erkrankungen  nach  Typhus  (Abstract).     Deutsche  med. 

Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41,  p.  331. 
Phocas,  D.     Accident  produit  par  I'eboulement.     Bull,  et  mem.  Soc.  de  chir. 

de  Par.,  1916,  v.  42,  pp.  2839-2840. 
Phocas,  et  Gutman,  R.  A.     L'hemiplegie  pleurale  traumatique.     Bull,  et  mem. 

Soc.  med.  d'  hop.  de  Par.,  191 5,  v.  39,  pp.  329-335. 
Physical  qualities  of  aviators.     Jour.  A.  M.  A.,  1918,  Ixiv,  37. 
Physical  tests  for  airmen  are  novel  and  exciting.     N.  Y.   Med.  Jour.,   1918, 

cviii,  690. 
Physical  treatment  for  disabled  soldiers.      Lancet,  Lond.,   1916,  i,  pp.  691- 

694. 
Pick,  A.     Der  Krieg  und  die  Reservekrafte  des  Nervenssystem.     Samml.  zwangl. 

Abhandl.  a.  d.  Geb.  d.  Nerv.  u.  Geisteskr.,  Halle  a.  S.,  1916,  v.  11,  No.  5, 

pp.  1-27. 
Pick,  W.     (Simulation  of  venereal  disease.)     Med.  Klin.,  Berl.  u.  Wien,  191 7, 

No.  6,  pp.  148-151.     Rev.  J.  Roy.  Nav.  M.  Serv.,  Lond.,  1917,  Oct.,  pp. 

497-498.  _  _  ,   ,  .    „ 

Pieron,     Henri.      "  Hyperesthesie  "     signine    toujours     '  Hyperalgesie.       Rev. 

neurol.,  Par.,  1914-15,  v.  22',  pp.  947-951. 
Pierre-Robin,  Dr.     Mecanotherapie  fonctionnelle.     J.  de  med.  et  de  chir.  prat., 

Par.,  1916,  V.  87,  pp.  309-320. 
Pighini,  G.     11  servizio  neuro-psichiatrico  nella  zona  di  guerra.     Ann.  di  manic. 

prov.  di  Perugia  (1915),  1917,  v.  9,  pp.  49-55. 
Pighini,   G.     Contributo  alia  clinica  e   patogenesi   delle  psiconeurosi  emotive 

osservate  al  fronte.     Riv.  sper.  di  freniat.,  Reggio-Emmilia,  1916-17,  xiii, 

298-343.  .  .      ,  , 

Rica,    A.     Zur   Aetiologie    und    Behandlung    der   progressiven    Analyse    nebst 

einigen   kriegspsychiatrischen   Erfahrungen.     Wien.  klin.  Wchnschr.,  1915, 

V.  28,  p.  633. 
Piotrowski.     Traumatische  Neurosen.     Neurol.  Centralbl.,  Leipz.,  1915,  v.  34, 

PP-  591-592- 
Pitres,  A.     Discussion  de  la  conduite  a  tenir  vis-i-vis  des  blessures  du  crane  — 

par  P.  Marie.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  470-471. 
Pitres,  A.     Etude  sur  les   principak-s  causes  d'erreurs  de  diagnostic  dans  les 

paralysies  des  membres  consecuiives  aux  blessures  des  nerfs.     J.  de  med. 

de  Bordeaux,  191 7,  v.  88,  pp.  239-247. 
Pitres,  A.     La  valeur  des  signes  cliniques  permettant  de  reconnaitre  dans  les 

blessures  des  nerfs  peripheriques:    A.  La  section  complete  du  nerf;    B.  La 

restauration  fonctionnelle.     Soc.  de  Neurol.  April  6,  1916.     Revue  Neurol. 

April-May,  19 16. 
Pitres,  A.     Sur  les  processus  histologiques  qui  president  a  la  cicatrisation  et  k  la 

restauration  fonctionnelle  des  nerfs  traumatismes.     Journ.  de  Med.  de  Bor- 
deaux, Dec,  1915. 
Pitres,  A.  et  Marchand,  L.     Quelques  observations  de  syndromes  commotion- 

nels  simulant  des  affections  organiques  du  systeme  nerv^eux  central  (men- 

ingite  paralysie  generale,  lesions  cerebelleuses,  sclerose  en  plaques,  tabes). 

Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  298-311. 
Placido,  C.     Delinquenza  militaire  in  pace  ed  in  guerra.     Ann.  di  manic,  prov. 

di  Perugia  (1915).  iQi?,  v.  pp.  25-47. 


BIBLIOGRAPHY  i^i 

Plantier.  Une  application  medicale  de  I'esperanto  comme  moyen  de  reeduca- 
tion psychique.     Paris  med.  (Part,  paramed.),  1916,  v.  22,  pp.  195-197. 

Podiapolsky.  Application  de  la  suggestion  hypnotique  dans  la  pratique  des 
hopitaux  militaires.     (Jour,   de  neurop.   et  psychiat.   de  S.   S.,   KorsakoflF, 

1916,  fasc.  2),  Rev.  neuroL,  Par.,  1917,  v.  24,  pp.  477-478. 
Podiapolsky,  P.  P.     La  suggestion  hypnotique  a  I'hopital  de  camp.     Paris  med., 

1917,  No.  34,  pp.  165-170. 

Podmaniczky,  B.  T,  von.     Die  Lumbalpunktion  als  therapeutische  Hilfsmittel  bei 

gewissen   Formen   der   Kriegshysterie.     Wien.   klin.  Wchnschr.  1916,  xxLx, 

1396. 
Podmaniczky,  T.     Einige  interessante  Falle  von  Kriegsneurosen.     Pest,  med.- 

chir.  Presse,  Budapest,  1915,  v.  51,  p.  81. 
Podmaniczky.     Die  Lumbalpunktion  als  therapeutische  Hilfsmittel  bei  gewissen 

Formen  von  Kriegshysterie.     Wien.  klin.  Wchnschr.,  1916,  v.  29,  No.  44, 

p.  1396. 
Pollosson  at  Collet.     Epilepsie  partielle  continue  d'origine  traumatique.     Tre- 
panation.    Guerison.     Rev.  neurol..  Par.,  1914-15,  v.  22^,  pp.  291-295. 
Popoff,  N.  F.     (Rare  case  of  self  injury  to  avoid  military  service).     Voyenno  Med. 

J.,  Petrogr.,  1915,  v.  242,  med.  spec,  pt.,  pp.  288-292. 
Poppelreuter,  Walter.     Psychische  Ausfallserscheinungen     nach  Hirnverletzun- 

gen.     Aertzl.   Centralbl.   Zeit.,   1915,  v.   27,  p.   152.     Also  Munchen.  med. 

Wchnschr.,  1915,  v.  62,  pp.  489-491. 
Porak,  Rene.     Nouveaux  signes  physiologiques  des  psychonevroses  de  guerre. 

Compt.  rend.  Soc.  de  biol..  Par.,  1916,  v.  79^,  pp.  630-634. 
Porot,  A.     Les  bases  de  I'expertise  mentale  dans  les  bataillons  d'Afrique  et  les 

groupes  speciaux  en  temps  de  guerre.     Rev.  neurol..  Par.,  1916,  v.  23,  pp. 

24-27. 
Porot,  A.     Les  bases  de  I'expertise  mentale  dans  les  bataillons  d'Afrique  et  des 

groupes  speciaux  en  temps  de  guerre.     (Aptitude  au  service  et  responsibilite). 

Caducee,  Par.,  1916,  v.  16,  pp.  85-87. 
Porot,  A.     Sur  les  accidents  nerveux  determines  par  la  deflagration  de  fortes 

charges  d'explosifs.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  603-605. 
Porot  and  Gutmann,  R.  A.     Centre  neurologique  de  la  19*^  region  (Alger).     Rev. 

neurol..  Par.,  1916,  v.  23,  pp.  726-733. 
Porot  et  Gutmann.     Les  psychoses  du  paludisme.     Paris  med.,  1917,  7,  518-22. 
Porter,  W.  T.  and  Emerson,  E.     Wound  shock  and  the  vasomotor  center.     Bos. 

M.  and  S.  J.,  1918,  clxxix,  275. 
Porter,  William  Townsend.     Shock  at  the  Front.     Atlantic  Monthly  Press,  1918. 
Porter,  W.  T.     Shock  at  the  front.     Boston  M.  and  S.  J.,  1916,  v.  175,  pp.  854- 

858. 
Porter,  William  T.     Traumatic  shock.     Bos.  M.  &  S.  J.,  1918,  clxxviii,  657. 
Porter,  W.  T.     Further  observations  on  shock  at  the  front.     Boston  M.  and  S.  J., 

1917,  V.  177,  pp.  327-328. 
Previously  insane  recruit.     N.  York  M.  J.,  1916,  v.  104,  p.  857. 
Pribram,  B.  O.     Erfolge  und  Misserfolge  bei  der  operativen  Behandlung  der 

Schadelschiisse,  besonders  der  Durchschiisse.     Wien.  klin.  Wchnschr.,  1915, 

V.  28,  pp.  1025-1028. 
Priest,  E.     Massage  in  the  after-treatment  of  the  wounded.     Lancet,  Lond., 

1915,  ii,  p.  1052. 
Prince,  Morton.     Prevention  of  so-called  shell  shock.     J.  Am.  M.  Ass.,  Chicago, 

1917,  V.  69,  pp.  726-727. 
Privat,  J.     La  mecanotherapie  de  guerre.     Bull.  Acad,  de  med..  Par.,  1915,  v.  73, 

pp.  411-416.     Also  Rev.  gen.  de  clin.  et  de  therap..  Par.,  1915,  v.  29,  pp.  219, 

234,  250,  266. 
Privat,  J.     La  mechanotherapie  de  .s:uerre.     191 5,  Paris,  A.  Maloine. 
Problem,  (The)  of  the  insane  sailor  and  soldier.     Lancet,  Lond.,  191 7,  ii,  612. 
Proctor,  A.  P.     Three  cases  of  concussion  aphasia:   treatment  by  general  anes- 
thesia.    Lancet,  Lond.,  1915,  ii,  p.  977- 
Prozoroff,  L.  A.     (Organization  of  aid  to  insane  soldiers).     Psikhiat.  Gaz.,  Pet- 
rogr., 1915,  V.  2,  p.  167. 
Prusenko,  A.  I.     (Conditions  of  ner^'ous  and  insane  soldiers  in  the  Caucasian 

front).     Psikhiat.,  Mosk.,  1915,  v.  9,  pp.  291-293. 


962  BIBLIOGRAPHY 

Pruvost,  L.  P.     Les  debiles  mentaux  k  la  guerre.     Leur  utilisation.     Theses  de 

Paris,  1915-16,  V.  10,  No.  23. 
Psyche  und  Kriegserfahrungen.     Discussion  von  Bonhoeffer,  Meyer.     Berl.  klin. 

Wchnschr.,  1916,  v.  532,  pp.  1206-1207. 
Psychiatrie  iind  Krieg.     Psychiat.  neurol.  Wchnschr,     Halle  a.  S.,  1914-1915, 

V.  16,  pp.  284-285. 
Psychological  Examining  in  the  Army.     Amer.  Jour.  Med.  Sc,  1918,  civ,  128. 
Purser,  F.  C.     Shell  shock.     Report  of  Section  of  Medicine  of  the  Royal  Academy 

of  Medicine  in  Ireland.     Brit.  M.  J.,  1917,  ii,  p.  81. 
Fhirser,  F,  C.     Shell  shock.     Dublin  J,  M.  Sc.,  1917,  v.  144,  p.  206. 
Quaet-Faslem.        Die     allgemeine     nervosa    Erschopfung.        Psychiat  .-neurol. 

Wochnsch.,  19,  1917-8. 
Qiiidot,  L.     Deux  epreuves  pratiques  pour  depister  les  simulateurs  de    surdite. 

Presse  med..  Par.,  1917,  v.  25,  p.  515. 
Rablofsky.     (War  hysteria,  traumatic  neuroses),     Wien.  klin.  Wchnschr.,  1916, 

v.  29,  p.  1616. 
Radcliffe,  Frank.     Hydrotherapy  as  an  agent  in  the  treatment  of  convalescents. 

Brit.  M.  J.,  Lond.,  1916,  ii,  p.  554. 
Raether,  M.     Neurosen-Heilungen  nach  der  "  Kaufmann-Methode."     Arch,  f, 

Psychiat.,  Berl.,  1917,  57,  489-518. 
Raether,  M.     Ueber  psychogene  "  Ischias-Rheumatismus  "  und  "  Wirbelsaulen- 

erkrankungen."     Arch.  f.  Psychiat.,  Berl.,  1917,  57,  772-791. 
Raeuber.     Die  Beschaftigung  und  Arbeitverwendung  der  Kriegsbeschadigten  auf 

Grund  eigener  Erfahrung.     Ztschr.  f.  Med.  Beamte,  Berl.,  1917,  30,  441. 
Baffaete,    R.     Considerazioni   su    una   centuria  di  casi  di  patomimia  cutanea 

(durante  un  anno  dell'attuale  campagna,  1915-16).     Gior.  ital.  d.  mal.  ven., 

Milano,  1916,  Ii,  415-420. 
Raffegeau,  du  Vesinet.     Note  sur  un  cas  de  seton  du  crane  par  balle  de  mitrail- 
leuse.    Ann.  med.-psychol..  Par.,  191 7,  v.  73,  pp.  101-104. 
Raimann,  E.     Ein  Fall  von  "  Kriegspsychose."     Wien.  klin.  Wchnschr.,  1916,  v. 

29,  pp.  42-47. 
RamoDd  et  De  la  Grandiere.     Troubles  de  la  sensibilite  au  cours  de  la  diph- 
theric.    L'hysterie  diphtherique.     Presse  med..  Par.,  1916,  v.  24,  p.  523. 
Ramsay,  A.  M.,  Grant,  Dundas,  Whale,  H.  L,,  West,  C.  E.     Injuries  of  eyes,  nose, 

throat  and  ears.     London,  1915,  Oxford  Press,  160  pp.,  12°. 
Rautenberg,  H.     Wert  der  Abderhaldenschen  Dialysieverfahrens  fur  die  Kriegs- 

psychiatrie.     Deutsche  Mil.  arztl.  Ztschr.,  Berl.,  191 7,  46,  417-23. 
Raujard,  L.     Les  surdites  par  obusite.     Bull.  Acad,  de  med.  de  Par.,  1916,  v.  75, 

pp.  195-198. 
Ravaut,  Paul.     Les  hemorragies  internes  produites  par  le  choc  vibratoire  de  I'ex- 

plosif.     Presse  med..  Par.,  1915,  v.  23,  p.  114. 
Ravaut,  Paul.     Les  blessures  indirectes  du  systeme  nerveux  determines  par  le 

"  vent  de  I'explosif."     Presse  med.,  Par.,  1915,  v.  23,  pp.  313-315. 
Ravaut,  Paul.     Etude  sur  quelques  manifestations  nerveuses  determines  par  le 

"  vent  de  I'explosif."      Bull.  Acad,  de  med.,   Par.,  1915,  v.  73,  pp.  717- 

720. 
Ravaut,  P.  et  Renlac.     Intoxication  par  les  gaz  asphyxiants;  Diphtheric  second- 

aire  meconnue;    Paralysie  diphtherique  generalisee  avec  reaction  meningee. 

Bull,  et  mem.  Soc.  med.  des  hop.  de  Paris,  1917,  3  ser.,  41,  1 190-2. 
Rawling,  L.  Bathe.     Surgery  of  the  head.     191 5,  London,  Henry  Frowde. 
Rawling,  L.  Bathe.     Surgery  of  the  Head.     Oxford  War  Primers,  191 5. 
Raynal,  Albert  J.  L.     La  reeducation  motrice  chez  les  blesses  de  guerre.     Theses 

de  la  Faculte^de  Paris,  191 5-16,  v.  11. 
Raynaud.     Contracture  hysterique  du   membre  superieur  droit  avec  oedeme. 

Reunion  medicale  VI  armee,  4  aout,  1915,  et  Presse  med.,  1915. 
Raynier.     Les  etats  depressifs  et  les  etats  melancoliques  chez  les  militaires  pen- 
dant la  guerre.     J.  de  med.  et  de  chir.,  1915,  Feb.,  v.  86. 
Raymond,  Victor.     Les  desequilibres  mentaux  dans  I'armee.     Ann.  d'hyg..  Par,, 

1914,  V.  22,  pp.  305-330, 
Rebierre,  Paul.     Un  centre  psychiatrique  d'armee.     Arch,  de  med.  et  pharm. 

mil.,  Par.,  1916,  v.  65,  pp.  434-454- 
Rebierre,     Discussion  de  la  conduite  k  tenir  vis-a-vis  des  blessures  du  crane  — 

par  P,  Marie,     Rev.  neurol..  Par.,  1916,  v.  29,  p.  473. 


BIBLIOGRAPHY  963 

Rebierre.     Sur  les  accidents  nerveux  determines  par  la  deflagration  de  fortes 

charges  d'explosifs.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  597-598. 
Reconstruction  hospitals  and  orthopedic  surgery.     Science,  N.  Y.  and  Lancaster, 

Pa.,  1917,  n.  s.,  V.  46,  p.  305. 
Reconstruction  Hospitals.     Boston  M.  and  S.  J.,  191 7,  i,  p.  744. 
Recherche  de  I'acide  picrique  dans  les  iirines  et  dans  les  visceres.     See.  de  med. 

leg.  de  France,  Bull.,  Par.,  1916,  v.  12,  pp.  42-47. 
Redlich,   Emil.     Einige  allgemeine   Bemerkungen  uber  den   Krieg  und   unser 

Nervensystem.     Med.  Klin.,  Berl.  u.  Wien,  1915,  v.  iii,  pp.  467-473. 
Redlich,   Emil.      Bemerkungen    zur  Aetiologie   der   Epilepsie   mit    besonderer 

Berucksichtigung  der  Frage  einer  "  Kriegsepilepsie."     Wien.   med.  Wchn- 

schr.,  Nr.  17,  1918. 
Reeducation  fonctionnelle  et  reeducation  professionnelle  des  blesses.     (A  sym- 
posium study),  1917,  Paris,  J.  B.  Bailliere  et  Fils. 
Reeve,  E.  F.     The  treatment  of  functional  contracture  by  fatigue.     Lancet, 

Lond.,  1917,  ii,  pp.  419-421. 
Reformatski,  N.  N.     (Care  and  evacuation  of  insane  soldiers  to  the  rear  of  the 

armies  of  the  northwestern  front).     Russk.  Vrach.,  Petrogr.,  1915,  v.  14, 

pp.  677-679. 
Reformatski,  N.  N.     (Care  and  evacuation  of  insane  soldiers  from  the  active 

armies  in  the  northwestern  region).     Russk.  Vrach.,  Petrogr.,  1916,  v.  15, 

pp. 230-234. 
Reformatski,  N.  N.     (Organization  at  the  rear  for  the  care  and  evacuation  of 

insane  soldiers  in  the  northwestern  front).     Sovrem  Psikhiat.,  Mosk.,  1915, 

V.  9,  pp.  194-198. 
Reformatski,  N.  N.     (Care  and  evacuation  of  insane  warriors  of  the  active  army 

of  the  northwestern  region).     Sovrem.  Psikhiat.,  Mosk.,  1916,  v.  10,  pp.  118- 

128.     Also  Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  165-175. 
Regis,  E.     Les  troubles  psychiques  et  neuro-psychiques  de  la  guerre.     Presse 

med..  Par.,  1915,  v.  23,  pp.  177-179. 
Regis,  E.     Psychic  and  neuro-psychic  affections  in  war.     Boston  M.  and  S.  J., 

1916,  V.  174,  pp.  784-792. 
Regis,  E."     Les  alienes  militaires  internes  du  centre  psychiatrique  de  Bordeaux. 

Statistique  et  commentaires.     Caducee,  Par.,  1916,  v.  16,  pp.  55-59. 
Regis  et  Hesnard.     Un  cas  d'aphonie  hysterique  d'origine  emotive.     Le  r61e 

pathogene  des  emotions  oniriques.     Journal  de  Psychologie,  mai-juin  1913. 
Regnier,   P.     Organisation   scientifique   de   la  reeducation   professionnelle   des 

mutiles.     Rev.  scient..  Par.,  1916,  v.  2,  pp.  458-460. 
Regnier,  P.     De  la  reeducation  fonctionnelle  des  blesses.     Rev.  de  chir.,  Par., 

1916,  4.  35,  pp.  668-696. 
Renaux,  Jules,     fitats  confuslonnels  consecutifs  aux  commotions  des  batailles. 

(These,  Paris,  1915),  Presse  med.,  Par.,  1916,  v.  24,  p.  184. 
Renon,  Loiiis.     L'angoisse  de  guerre  et  son  traitement.     Bull.  gen.  de  thfirap., 

Par.,  1915-16,  V.  1681,  pp.  785-791;   also  pp.  821-827. 
Renon,  Loviis.     L'angoisse  de  guerre  et  son  traitement.     Rev.  gen.  de  clin.  et 

de  therap..  Par.,  1916,  v.  30,  pp.  41-43. 
Repkewitz.     Ueber  die  Simulation  und  Uebertreibung.     Neurol.  Centralbl.,  37, 

Nr.  12,  1918. 
Report  of  Dr.  Hemy  Carre.     Glasgow  District  Mental  Hospital,  Brit.  M.  J., 

Lond.,  1916,  i,  p.  148. 
Report.     War  Disablement  Committee.     Use  of  Remedial  Baths  in  connection 

with  other  physical  methods  in  the  treatment  of  disabled  soldiers.     Proc. 

Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10  (sec.  Balneol.),  pp.  78-80. 
Resch,   H.     Geisteskrankheiten  und  Krieg.     AUg.   Ztschr.  f.  Psychiat.,  Berl., 

1915.  V.  72,  No.  2  and  No.  3,  pp.  121-133. 
Responsabilite  des  oeuvres  de  reeducation  des  mutiles  de  guerre  au  point  de  vue 

des  accidents.     Ann.  d'Hyg.,  Par.,  191 7,  v.  25,  pp.  190-192. 
Revault  d'Allones,  G.     Le  signe   achilleen  sensitif   des  affections  du  nerf  sci- 

atique.     Press  med.,  Par.,  1917,  v.  25,  pp.  351-352- 
Richet,  Ch.     "  Anesthesie  "  en  dictionaire  de   physiologic.     Lyon   med.,    1915, 

V.  124,  p.  347. 
Richet,  Ch.     Le  courage,     Rev,  sc,  Par.,  1916,  ii,  pp.  385-391. 


964  BIBLIOGRAPHY 

Richet,  Ch.     Les  evenements  psychiques  de  la  guerre.     Un  appel  de  M.  Charles 

Richet   aux  soldats;    avez-vous  des  pressentiments?     Ann.  d.  sc.  psych., 

Par.,  1916,  xxvi,  185-192. 
Riddoch,  George.     Dissociation  of  visual  perceptions  due  to  occipital  injuries 

with  especial  reference  to  appreciation  of  movement.     Brain,  Lond.,  191 7, 

V.  40,  pp.  15-57- 
Riddoch,  George.     On  the  relative  perceptions  of  movement  and  a  stationary 

object  in  certain  visual  disturbances  due  to  occipital  injuries.     Proc.  Roy. 

Soc.  Med.,  Lond.,  1917,  v.  10,  No.  3  (Sect.  Neurol.),  p.  13. 
Riebeth.      Ueber      Neurasthenie      bei      Kriegsteilnehmern.      Psychiat.-neurol. 

Wchnschr.,  Halle  a.  S.,  1915-16,  v.  17,  p.  71. 
Rietschel,    H.        Die    Kriegsenuresis.        Miinch.     med.    Wchnschr.,    Nr.    26, 

1918. 
Riggall,  Robert  M.     The  treatment  of  neurasthenia  by  hypnotism.     J.  Roy. 

Nav.  M.  Serv.,  Lond.,  1917,  v.  3,  pp.  190-194. 
Rimbaud,  L.     A  propos  de  la  methode  de  traitement  des  psychonevroses  dite 

"  du  torpillage."     Marseille  med.,  1916,  v.  53,  pp.  33-41. 
Rimbaud,  L.     Le  traitement  des  psychonevroses  de  guerre  et  des  troubles  ner- 

veux  dits  "  reflexes."     Marseille  med.,  1917,  v.  54,  pp.  817-829. 
Rimbaud,   L.     Les   reflexes  de  percussion  plantaire  leur  valeur  diagnostique. 

Presse  med..  Par.,  1917,  v.  25,  pp.  539-540- 
Rippon,  T.  S.     Essential  characteristics  of  successful  and  unsuccessful  aviators. 

Lancet,  Lon.,  1918,  ii,  411. 
Rivers,  W.  H.  R.     A  case  of  claustrophobia.     Lancet,  Lond.,  191 7,  v.  2,  pp. 

237-240. 
Rivers,  W.  H.  R.     Freud's  psychology  of  the  unconscious.     (Evidence   afforded 

by  the  war.)     Lancet,  Lon.,  1917,  i,  912. 
Rivers,  W.  H.  R.     Repression  of  war  experience.     Proc,  Roy.  Soc,  of  Med., 

Lon.,  191 8,  xi  (Sec.  of  Psychiatry),  i. 
Rivers,  W.  H.  R.     The  repression  of  war  experience.     Lancet,  Lond.,  1918,  i, 

pp.  173-177- 

Rivers,  W.  H.  R.  War  neurosis  and  military  training.  Mental  Hygiene,  II, 
October,  191 8. 

Roberts,  John  B.     War  surgery  of  the  face.     1919. 

Robertson,  George  M.  War  and  alcohol  as  exciting  factors  in  the  onset  of  in- 
sanity.    Med.  Officer,  Lond.,  1915,  v.  14,  pp.  283-284. 

Robin,  Pierre.     Methode  de  prothese  fonctionelle.     Caducee,  Par.,  19 16,  v.  16, 

pp.  35-40- 
Roches,    H.    Louis.     Extraction    magnetique    des    projectiles    intracerebraux. 

J.  de  Radiol,  et  d.  electrol.  Par.,  1916,  v.  2,  pp.  165-172. 
Rochtein,  I.  D.     Contribution  a  I'etude  des  soi-disant  contusions  de  guerre  et 

de  leur  traitement.     Medecin  russe  pratique.  No.  24,  1915. 
Roemheld,     L.     Ueber     homolateral     Hemiplegien     nach     Kopfverletzungen. 

Miinchen  med.  Wchnschr.,  1915,  v.  62^,  pp.  600-601. 
Roeper,  E.     Zur  Prognose  der  Hirnschiisse.     (Aus  dem  Marinelazarett  Ham- 
burg.)    Munch,  med.  Wchnschr.,  191 7,  64.     Feldartzl.  Beil.  4  (Abstract  in 

Centralbl.  f.  Chir.,  Leipz.,  1917,  44,  1036). 
Roger,  H.     Simulation  des  oreillons.     Rev.  gen.  de  clin.  et  de  therap.,  Par., 

1916,  XXX,  80. 
Roger,  H.     Le  choc  nerv^eux.     Presse  med..  Par.,  1916,  v.  24,  pp.  513-516. 
Roger,  H.     Les  pseudo-erysipeles  de  la  face  provoques.     Marseille  med.,  1916-17, 

liii,  785-800. 
Roger,  H.     Deux  cas  de  tetanos  localise  post-serique.     Marseille  med.,   191 7, 

V.  54,  pp.  353-363. 
Rogues  de  Fursac,   J.     Un  cas  d'emotivite  morbide  chez  un  militaire.     Rev. 

neurol.,  Par.,  1914-15,  v.  22\  pp.  774-776. 
Role  de  1' auto-intoxication  dans  la  fatigue.     Presse  Med.,   Par.,   191 7.  v.  25, 

pp.  142-143  (or  102-103).  ,    „ 

Romer,  F.     Mechano-therapy  at  the   Corydon  War  Hospital.     J.  Roy.  Army 

Med.  Corps,  Lond.,  191 7,  v.  28,  pp.  578-585- 
Roncoroni,  L.     Quattro  casi  di  mutismo  di  guerra.     Boll.  d.  Soc.  med.  in  Parma, 

1915,  V.  8,  pp.  I14-I17. 


BIBLIOGRAPHY  965 

Roper.  Das  Hamburger  Marine-Lazarett.  Neurol.  Centralbl.,  Leipz.,  1^15, 
V.  34.  505-506. 

Roper.  Funlctionelle  Neurosen  bei  Kriegsnehmern.  Deutsche  mil.-artzl. 
Ztschr.,  Bed.,  1915,  Nos.  9-10,  p.  752. 

Roquette.  Sur  rinstallation  et  le  fonctionnement  de  I'hopital-depot  de  conval- 
escence Faucher.  Arch,  de  med.  et  pharm.  mil.,  Par.,  1914-15,  v.  64,  pp. 
206-232. 

Ross,  T.  A.  Prevention  of  relapse  of  hysterical  manifestations.  Lancet,  Lon., 
1918,  ii,  516. 

Rosenbach.     (Psychoses  of  war  time.)     Russk.  Vrach.,  Petrogr.,  191 5,  v.  14. 

Rosanoff,  A.  J.  First  psychiatric  experiences  at  the  National  Army  Canton- 
ment at   Camp  Upton,  Long  Island,  N.  Y.  Med.  Rec,  N.  Y.,  1917    xcii 

Rosanoff-Saloff,    Mme.     Considerations    generales    sur    la    camptocormie.     N. 

Iconog.  de  la  Salpetriere,  Par.,  1916-17,  v.  28,  pp.  28-33. 
Rose,   Felix.     Le  signe  de   fessier  dans   la   nevralgie  sciatique.      Presse  med., 

Par.,  1917,  V.  25,  p.  319. 
Rose  et  Villandre.     Cranioplastie  cartilagineuse  faite  apres  trepanation  pour  epi- 

lepsie  Jacksonienne.     Lyon  med.,  1916,  v.  125,  p.  348. 
Rosenfeld.     Ueber   Kriegsneurosen,   ihre   Prognose  und   Behandlung.     Arch.   f. 

Psychiat.,  Bed.,  1917,  57,  221-244. 
Roth,  E.     Kriegsgefahr  und  Psyche.     Aertztl.  Sachverst.-Ztg.,  Bed.,  1915,  v.  21, 

Rothacker,  A.  Einige  Falle  von  Hyperthyroidismus,  darunter  drei  von  akuten 
Basedow  bei  Kriegsteilnehmern  zur  Stutze  der  neurogenen  Entstehung 
dieser  Krankheit.     Miinch.  med.  Wchnschr.,  1916,  No.  3,  pp.  99-101. 

Rothmann,  Max.  Ueber  isolierte  Thermanalgesie  eines  Beines  nach  Schussver- 
letzung  des  obersten  Brustmarks.     Neurol.  Centralbl.,  Leipz.,  1915,  v.  34, 

PP-  153-157- 

Rothmann,  M.  Zur  Beseitigung  psychogener  Bewegungstorungen  bei  Soldaten 
in  einer  Sitzung.     Miinchen  med.  Wchnschr.,  1916,  v.  64,  No.  35. 

Rottenstein.     Les  phlegmons  provoques.     Marseille  med.,  1916-17,  lii,  801-807. 

Rouge,  C.  Influence  de  la  guerre  actuelle:  (i)  Sur  le  mouvement  de  la  popu- 
lation de  I'asile  de  Limoux  du  2  aout  1914  au  31  decembre  1915;  (2)  Sur 
les  psychoses  des  alienes  internes  pendant  la  meme  epoque.  Ann.  med.- 
psychol..  Par.,  1916,  v.  7,  p.  425. 

Roussy,  G.  Accidents  nerveux  produits  a  distance  par  eclatement  d'obus. 
Rev.  neuroL,  Par.,  1914-15,  v.  22^,  pp.  2i6-2i7._ 

Roussy,  G.  Boisseau,  J.  and  d'Oelnitz,  M.  Emotions  de  guerre.  Collection 
Horizon,  Masson  et  Cie,  Paris,  1918. 

Roussy,  Gustave.  Complications  of  wounds  of  the  spinal  cord.  War  Med., 
Surg,  and  Hygiene,  1918,  i,  602. 

Roussy,  G.  Psycho-neurological  disturbances  affecting  the  limbs,  observed 
during  the  war.     War  Med.,  1918,  ii,  37. 

Roussy,  G.  Surdite-mutite  par  eclatement  d'obus  chez  trois  Zouaves  compa- 
gnons  d'armes.     Rev.  neurol..  Par.,  1914-15,  v.  22^,  pp.  394-396. 

Roussy,  G.  A  propos  de  quelques  troubles  nerveux  observes  a  I'occasion  de  la 
guerre  (hysterie,  hysterie-traumatisme,  simulation).  Rev.  neurol.,  Par., 
T914-15,  V.  22^,  pp.  425-430.     Also  Presse  med..   Par.,   1915,  v.  23,  pp. 

115-117- 
Roussy,  G.     Troubles  nerveux  psychiques  de  guerre.     Presse  med..  Par.,  1915, 

V.  23,  p.  141. 
Roussy,  G.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  crane 

—  par  P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  p.  472. 
Roussy,  G.     Sur  la  frequence  des  complications  pleuro-pulmonaires  et  leur  role 

comme  facteur  de  gravite  chez  les  grands  blesses  nerveux.     Bull.  Acad,  de 

med.,  Par.,  1916,  v.  75,  p.  722-725.     Also  Presse  med..  Par.,  1916,  v.  24, 

p.  266.  ,   . 

Roussy,  G.     Un  cas  de  tumeur  de  lobe  frontal  pris  cliniquement  pour  une  menm- 

gite  tuberculeuse.     Presse  med.,  Par.,  1916,  v.  24,  p.  47. 
Roussy,   G.     Des  complications  pleuro-pulmonaires  comme  facteur  de  grayite 

chez  les  blesses  du  crane  et  de  la  moelle  par  plaie  de  guerre.     Presse  med.. 

Par.,  1916,  V.  24,  p.  47. 


966  BIBLIOGRAPHY 

Roussy,  G.  Un  cas  de  paraplegic  hysterique  datant  de  21  mois  avec  gros 
troubles  vaso-moteurs  thermiques  et  secretoires  des  extremites  inferieures. 
Rev.  neurol.,  Par.,  1917,  v.  24,  pp.  253-256. 

Roussy  et  Boisseau.  Fausse  commotion  cerebrale.  Begaiement  hysterique. 
Presse  med.,  Par.,  1915,  v.  23,  p.  391. 

Roussy  et  Boisseau.  Les  sinistroses  de  guerre.  Accidents  nerveux  par  eclate- 
ment  d'obus  a  distance.     Presse  med..  Par.,  1915,  v.  23,  pp.  452-453. 

Roussy  et  Boisseau.  Discussion  de  accidents  nerveux  par  la  deflagration  ex- 
plosifs.     Rev.  neurol.,  Par.,  1916,  v.  23,  pp.  577-586. 

Roussy  et  Boisseau.  Un  centre  de  neurologic  et  de  psychiatric  d'armee.  Paris 
med.,  1916  (Part,  med.),  v.  19,  pp.  14-20.  ^ 

Roussy  et  Boisseau.  Les  accidents  nerveux  determines  par  la  deflagration  des 
explosifs.     Paris  med.,  1916-17,  v.  21,  pp.  185-191. 

Roussy  et  Boisseau.  Sur  le  pronostic  et  le  traitcment  des  troubles  nerveux  dits 
reflexes.     Rev.  neurol..  Par.,  1917.  y-  24,  pp.  516-527. 

Roussy  et  Boisseau.  Deux  cas  de  soi-disante  commotion  labyrinthique  par 
eclatement  d'obus  a  distance.     Presse  med..  Par.,  191 7,  v.  25,  p.  323. 

Roussy  et  Boisseau.  Pronostic  et  traitcment  des  troubles  nerveux  dits  reflexes. 
Presse  med.,  Par.,  191 7,  v.  25,  p.  374. 

Roussy  et  Boisseau.  Deux  cas  de  pseudo-commotion  labyrinthique  par  eclate- 
ment d'obus  a  distance  (commotion  labyrinthique  perseveree  simulee  ou 
suggestionnee).  Bull.  et.  mem.  soc.  med.  d'hop.  de  Par.,  1917,  v.  33,  pp. 
671-676. 

Roussy,  Boisseau  et  Comil,  L.  Pseudo-tympanites  abdominales  hysteriques;  les 
catiemophrenoses.  Bull,  et  mem.  Soc.  med.  d'hop.  de  Par.,  191 7,  v.  41,  pp. 
665-670. 

Roussy,  Boisseau  et  d'Oelsnitz.  La  station  neurologique  de  Salins  (Jena)  apres 
trois  mois  de  fonctionnement  (Projections  de  films  cinematographiques). 
Bull,  et  mem.  Soc.  med.  d'hop.  de  Par.,  191 7,  v.  33,  pp.  643-644. 

Roussy,  Boisseau  et  d'Oelsnitz.  Sur  I'influcnce  du  facteur  psychique  dans  la 
guerison  des  psychonevroses  de  guerre.  Presse  med.,  Par.,  191 7,  v.  25,  pp. 
413-414.     Also  Rev.  neurol..  Par.,  1917,  v.  24,  pp.  545-553. 

Roussy,  Boisseau  et  d'Oelsnitz.  Traitcment  des  psychonevroses  de  guerre. 
Collection  Horizon,  Masson  et  Cie,  1918. 

Roussy,  Comil  et  Leroux.  Les  manoeuvres  d 'elongation  du  nerf  dans  le  diagnos- 
tic des  sciatiques.     Presse  med.,  Par.,  191 7,  v.  25,  pp.  506-508. 

Roussy,  G.,  Lhermitte,  J.  The  psychonevroses  of  war.  Military  Medical 
Manuals,  Univ.  of  London  Press,  19 18. 

Roussy,  G.  and  Lhermitte,  J.  Blessures  de  la  moelle  et  la  queue  de  cheval.  Col- 
lection Horizon,  Masson  et  Cie,  Paris,  1917. 

Roussy,  G.  and  Lhermitte,  J.  Psychonevroses  de  guerre.  Collection  Horizon, 
^Iasson  et  Cie,  Paris,  191 7. 

Roussy  et  Lhermitte.  Les  psychonevroses  de  guerre.  Ann.  de  med..  Par..  191 6, 
V.  3,  pp.  525-563;   also  pp.  619-665. 

Roussy  et  Lhermitte,  J.  La  forme  hemiplegique  de  la  commotion  directe  de  ia 
moelle  cervicale  avec  lesion  de  la  XI*  paire  cranienne.  Ann.  de  med.,  Par., 
191 7,  V.  4,  pp.  458-469- 

Roussy  et  Ichlonski.  Mouvements  syncinesiques  tres  prononces  chcz  un  hemi- 
plegique organique  par  blessure  de  guerre.  Rev.  neurol.,  Par.,  1914-15,  v. 
22«,  pp.  492-494- 

Rentier.  Notes  a  propos  d'un  certain  nombre  de  cas  de  tetanos  anormal.  Bull. 
Acad,  de  med..  Par.,  1915,  v.  74,  pp.  515-516;   also  pp.  600-611. 

Rows,  R.  G.  Mental  conditions  following  strain  and  nervous  shock.  Brit.  M.  J., 
Lond.,  1916,  i,  pp.  441-443. 

Rucker.  Le  service  d'isolement  et  de  psychotherapie  a  la  Salpetrierc  pour  le 
traitcment  des  militaires  atteints  de  troubles  fonctionnels  du  systeme  ner- 
veux.    J.  de  med.  et  de  chir.  prat.,  Par.,  1916,  v.  87,  pp.  90-94. 

Russca,  Franchino.  ExperimentcUc  Untcrsuchungen  iiber  die  traumatischen 
Druckwirkung  der  Explosioncn.     Deutsche  Ztschr.  f.  Chir.,  1914-15,  v.  132, 

PP-  315-374- 
Russel,  Colin  K.     A  study  of  certain  psychogenctic  conditions  among  soldiers. 
Canad.  Med.  Ass.  J.,  Montreal,  1917,  v.  7,  No.  8,  pp.  704-720. 


BIBLIOGRAPHY  967 

Ryan,  E,     A  case  of  shell  shock.     Canad.  Prac.  and  Rev.,  Toronto,  1916,  v.  41, 

PP-  507-510-     Also  Canad.  Med.  Ass.  J.,  Montreal,  1915,  v.  6,  pp.  1095- 

1099. 
S.  (C.)     Le  service  d'isolement  et  de  psychotherapie  a  la  Salp6triere  pour  le  traite- 

ment  des  militaires  atteints  de  troubles  fonctionnels  du  systeme  nerveux. 

J.  de  med.  et  de  chir.  prat.,  1916,  Ixxxvii,  90-94. 
S.  (C.)     Les  blessures  indirectes  du  systeme  nerveux  determinees  par  le  vent  de 

I'explosif.     J.  de  med.  et  chir.  prat.,  Par.,  1916,  Ixxxvii,  436. 
Saaler,  B.     Ueber  nervose  und  psychische  Krankheiten  in  ihren  Beziehungen  zum 

Kriegsdienst.     Bed.  klin.  Wchnschr.,  1916,  liii,  1389. 
Sabrazis.     Simulation  de  meningite  cerebro-spinale  par  les  accidents  nerveux  du 

1914,  dans  deux  cas  guerison.     Gaz.  hebd.  d.  sc.  med.  de  Bordeaux,  1917,  v. 
38,  pp.  134-135- 

Sainsbury,  H.     Treatment  of  neuritis,  with  special  reference  to  sciatica.     Lancet, 

Lon.,  1917,  i,  911. 
Salmon,  Thomas  W.     Care  and  treatment  of  mental  diseases  of  war  neuroses 

("  shell  shock  ")  in  the  British  Army.     Nat.  Com.  Ment.  Hyg.,  1917. 
Salmon,  T.  W.     Outline  of  American  plans  for  dealing  with  war  neuroses.     War 

Med.,  1918,  ii,  34. 
Salmon,  Thomas  W.     The  care  and  treatment  of  mental  diseases  and  war  neuroses 

("  shell  shock  ")  in  the  British  Army.      Ment.  Hyg.,  Concord,  N.  H.,  1917, 

v.  I,  pp.  509-547- 
Salmon,  Thomas  W.     The  use  of  institutions  for  the  insane  as  military  hospitals. 

Ment.  Hyg.,  Concord,  N.  H.,  1917,  v.  7,  pp.  806-812. 
Salmon,  Thomas  W.     Recommendations  for  the  treatment  of  mental  and  nervous 

diseases  in  the  United  States  Army.     Psychiat.  Bull.,  Utica,  1917,  v.  2,  No. 

3,  PP-  355-376. 
Samuel.     Neurologische  Beobachtungen  bei  den  Truppen.     Berl.  klin.  Wchnschr. 

1915,  V.  52S  PP-  140-141- 

Sandberg.  Zwei  Falle  von  traumatischer  Hysterie  nach  Granatsplitterver- 
letzung.     Zentralbl.  f.  Chir.,  Leipz.,  1915,  v.  42\  pp.  221-222. 

Sandoz,  F.  Le  mecanotherapie  des  raideurs  articulaires  consecutifs  aux  bles- 
sures de  guerre.     Paris  med.,  1914-15  (Part,  med.),  v.  15,  p.  408. 

Sanger.  Ueber  die  durch  den  Krieg  bedingten  Folgezustande  im  Nervensystem. 
Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  ii,  p.  815.  Also  Berl.  klin. 
Wchnschr.,  1915,  v.  42^,  p.  277,  and  Neurol.  Centralbl.,  Leipz.,  1915,  v.  34, 
PP-  364-366. 

Sanger  and  Cimbal.  Nervose  Erkrankungen  im  Kriege.  Deutsche  med. 
Wchnschr.,  Leipz.  u.  Berl.,  1915,  v.  41,  p.  902;   also  933-935- 

Sarbo,  A.  v.  Ueber  den  sogennanten  Nervenschock  nach  Granat-  und  Schrapnell- 
explosionen.  Wien.  klin.  Wchnschr.,  19 15,  v.  28,  pp.  86-91.  Also  Psy- 
chiat.-Neurol.  Wchnschr.,  Halle  a.  S.,  1914-15,  v.  16,  pp.  429-431,  and 
Miinchen.  med.  Wchnschr.,  1915,  v.  621,  p.  230. 

Sarbo,  A.  Ueber  die  durch  Granat-  und  Schrapnell-explosionen  entstandenen- 
Zustandsbilder.     Ihid.,  608-616. 

Sarbo,  A.  v.     (Nerve  shock  following  grenade  and  shrapnel  explosions).     Orvosi 

t  *?     hetil.,  Budapest,  1915,  v.  59,  pp.  45-48. 

Sarbd,  A.  v.  Durch  Schrapnel  und  Granatexplosion  herbeigefiihrter  sogenannter 
Nervenschock.     Pest.  med.  chir.  Presse,  Budapest,  1915,  v.  51,  p.  21. 

Sargeant,  P.  and  Holmes.     Report  of  the  later  results  of  gunshot  wounds  of  the 

I  head.     J.  Roy.  Army  Med.  Corps,  Lond.,  1916,  v.  57,  pp.  300-311. 

Sauer,  W.     Enuresis  und  Hypnose  im  Felde.     Miinchen  med.  Wchnschr.,  1916, 

!  v.  63,  pp.  102-103. 

Savage,  George  H.     Mental  disabilities  for  war  service.     J.  Ment.  Sc,  Lond., 

1916,  ii,  p.  42;  also  V.  62,  pp.  653-657. 

Savage,  George  H.,  Sir.     Mental  war  cripples.     Practitioner,  1918,  c.  i. 
Savariaud.     A  propos  des  phlegmons  provoques  par  les  injections  de  petrole. 

Bull,  et  mem.  Soc.  de  chir.  de  Par.,  1915,  n.  s.,  xli,  2364. 
Sawdon.     Treatment  by  physical  methods  of  mental  disabilities  induced  by  the 

war.      Proc.   Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10  (sect.  Balneol.),  pp. 

42-44. 
Sayer,  Ettie.     The  organization  of  electrotherapy  in  military  hosp  tals.      Proc. 

Roy.  Soc.  Med.,  Lond.,  1915-16,  v.  9  (Electro-therap.  sect.),  p.  39. 


968  BIBLIOGRAPHY 

Scarisbrick,  W.     Cardiac  diseases  in  soldiers  and  recruits.     Brit.  Med.  Jour., 

1917,  i.  254. 
Schermers,  D.     Oorlogsneurosen  en   Psychosen.     Med.  Weekbl.,  Amst.,  1916- 

17,  V.  23,  pp.  109-112. 
Schier,  A.  R.     A  further  study  of  mental  tests  in  the  examination  of  recruits. 

U.  S.  Nav.  M.  Bull.,  Wash.,  1917,  v.  9,  pp.  325-333- 
Schiffbauer,  H.  E.     Operative  treatment  of  gunshot  injuries  to  the  peripheral 

nerves.     S.  G.  O.,  1916,  xxii,  133. 
Schlachter,  J.     Psychogener  Stridor  bei  Soldaten.     Ztschr.   f.  Ohrenheilh.,  77, 

1918. 
Schlayer.     Vorschlage  sur  Versorgung  der  funktionellen  Neurosen.  Miinchen  med. 

Wchnschr.,  1916,  No.  46,  pp.  1645-1646. 
Schlayer.     Die  Versorgung  der  funktionellen  Kriegsneurosen.    Miinchen    med. 

Wchnschr.,  191 7,  No.  i,  p.  39. 
Schlendler,   L.     Schadelverletzungen.     Bruns'    kriegschir.     Hefte   d.    Beitr.     z. 

klin.  Chir.,  Tubing,  1916,  103,  500. 
Schlesinger,  H.     Fall  von  hochgradiger  retrograder  Amnesic  nach  Gehirnver- 

letzung.     Wien.  med.  Wchnschr.,  1915,  No.  49,  p.  1815. 
Schlesinger,    H.     Hochgradige    retrograde    Amnesie    nach    Gehirnverletzung. 

Wien.  klin.  Wchnschr.,  1915,  xxviii,  1329. 
Schlesinger,  H.     Epilepsie  und  Anfall  Temperaturerhohungen.      Klin,  therap. 

Wchnschr.,  Wien  u.  Berl.,  1916,  v.  33*,  p.  29. 
Schmidt,  G.  B.     Chirurgische  Behandlung  der  Kriegsverletzungen  peripherischer 

Nerven.     Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41^  pp.  1263- 

1264. 
Schmidt,  W.     Die  psychischen  und  nervosen  Folgezustande  nach  Granatexplo- 

sionen  und  Minenverschiittungen.     Ztschr.  f.  d.  ges.   Neurol,  u.  Psychiat., 

Berl.  u.  Leipz.,  1915,  v.  29,  pp.  514-542. 
Schneider,  E.     Zur  Klinik  und  Prognose  der  Kriegsneurosen.     Wien.  klin.  Wchn- 
schr., 1916,  v.  29,  pp.  1295-1303. 
Scholtz,  W.     Funktionelle  Sprachlahmung  im  Felde.     Med.  Klin.,   Berl.,   1915, 

v.  II^  pp.  1 423-1 424. 
Schroder,   P.     Traumatische  Psychosen.     Monatschr.  f.  Psychiat.  u.  Neurol., 

Berl.,  1915,  No.  4,  pp.  193-201. 
Schiiller,  A.     Pulsus  paradoxus  respiratorius.     Klin,  therap.  Wchnschr.,  Wien 

u.  Berl.,  1916,  V.  3^,  pp.  28-29. 
Schiiller,  A.     Hypertrichose  bei  Ischiadicuslasionen.     Wiener  med.  Wchnschr., 

Nr.  46,  1917. 
Schultz,  J.  H.     Einige  Bemerkungen  iiber  Feindschaftsgefiihle  im  Felde.     Neurol. 

Centralbl.,  Leipz.,  1915,  v.  34,  pp.  373-378. 
Schultz,    J.    H.     Wege    und    Ziele   der    Psychotherapie.     Therap.    Monatschr. 

Berl.,  191 5,  No.  8,  pp.  443-450. 
Schultz,  J.  H.     Fiinf  neurologisch  bemerkungswerte  Hirnschiisse.     Monatschr. 

f.  Psychiat.  u.  Neurol.,  1916,  v.  39,  No.  6,  p.  319. 
Schultz,  J.  H.  and  Meyer,  Robert.     Zur  klinischen  Analyse  der  Granatschock- 

wirkung.     Med.  Klin.,  Berl.  u.  Wien,  1916,  v.  12,  pp.  230-233. 
Schultze,    Otto.     Ueber    die   Kaufmanns'sche   Behandlung    hysterischen   Bewe- 

gungsstorungen.     Miinch.  med.  Wchnschr.,  19 16,  No.  38,  pp.  1 349-1 353. 
Schuster.     Kriegsneurologische   Demonstrationen.     Neurol.    Centralbl.,    Leipz., 

1915.  V.  34,  pp.  1914-1916. 
Schuster.     Crampusneurose.     Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  p.  72. 
Schuster.      Entstehen  der  traumatischen   Neurosen   oder   Psychosen?     Neurol. 

Centralbl.,  Leipz.,  1916,  v.  35,  No.  12. 
Schuster.     Kriegsneurologische  Demonstrationen.     Berl.  klin.  Wchnschr.,  1916, 

No.  I,  pp.  24-25. 
Schuster,  Bonhoeffer,  Oppenheim.     Diskussion  —  Zerebellare  Symptomen-Kom- 

plexe    nach    Kriegsverletzungen.     Neurol.    Centralbl.,  Leipz.,   1915,   v.   34, 

pp.  664-666. 
Schuster.     Der    Mechanismus  der  hysterischen    Skoliose.     Neurol.   Centralbl., 

Leipz.,  37,  Nr.  18,  1918. 
Sebileau,  Pierre.     Monoplegie  du  membre  inferieur,  consequence  d'un  coup  de 

feu  de  la  cuisse  sans  blessure  apparente  de  I'appareil  d'innervation.     Bull. 

et  mem.  Soc.  de  chir.  de  Par.,  1914-15,  v.  40,  pp.  1175-1177. 


BIBLIOGRAPHY 


969 


Seelert,  H.     Ueber  Neurosen  nach  Unfallen  mit  besonderer  Beriicksichtigung 

von  Erfahrungen   im    Kriege.     Monatschr.   f.   Psychiat.   u.   Neurol.    Bed 
195,  V.  38,  pp.  328-340. 
Seelert,  H.     Differentialdiagnose  der  Hysterie   und  des  progressiven  Torsion- 

spasmus.     Arch.  f.  Psychiat.,  Berl.,  1918,  v.  56,  pp.  684-688. 
Seeuwen,  H.  J.     Heart  and  active  service.     Lancet,  Lon.,  1916,  ii,  432. 
Seeuwen,  H.  J.     Treatment  of  the  wounded  by  means  of  electricity.      .\rch.  of 

Radiol,  and  Electrotherap.,  1917,  xxii,  136. 
Segalcff,  T.  E.     Contribution  a  I'etude  des  lesions  organiques  et  fonctionnelles 

dans   les   contusions   par   eclat ements   d'obus.     Psychiatric   contemporaine 

russe,  1015;    Re\-ue    Neurol.  1914-15,  II,  p.  1081-1082. 
Segalcff,  T.  E.     Nature  of  contusions  caused  by  artillery  fire.     Morbus  decom- 

pressionis.     Sevrem.  Psikhiat.,  Mosk.,  1915,  ix,  103,  263,  405. 
Segalcff,   T.   E_.    (de   }vIoscou.)      Contribution   a    la  connaissance  de  la  nature 

des  contusions  par  les  obus  actuels.     Psychiatrie  contemp.  russe,  19 15. 
Self-mutilation  by  soldiers.     Brit.  \l.  J.,  Lo'nd.,  1915,  i,  p.  899. 
Sencert,  L.     Rupture  des  deux  poumons  par  le  "  vent  du  boulet."     Bull,  et  mem. 

Soc.  de  chir.  de  Par.,  1915,  v.  41,  pp.  79-82. 
Sensory  phenomena  in  head  injxiries.     Brit.  AI.  J.,  Lond.,  1915,  i,  p.  738. 
Seppilh,  G.     Guerra  e  psicopatie.     Gazz.  med.  d.  Marche,  Ancona,  1915,  v.  23 

No.  6,  p.  3. 
Seppilli,  G.     I  disturbi  mentali  nei  militari  in  rapporto  alia  guerra.     Riv.   ital. 

di    neuropat.    etc.,    Catania,    1917,    v.    10,    pp.    105-114;     also    pp     137- 

141. 
Sereysky,   M._  J.     (A   contribution   to  the   problem   of   poisoning  by   German 

asph>^>dating  gas:    Their  influence  in  the  ners-ous  psychic  condition  of  the 

asph3^xiated.)     Russk.  Vrach.,  Petrogr.,  1917,  v.  16,  p.  401. 
Serieux,   P.   et  Laignel-Lavastine.     Sur   utilite  de  mesures  speciales  pour  les 

anormaux  psychiques  constitutionnels  en  temps  de  guerre.     Bull,  med..  Par., 

1917,  V.  31,  pp.  11-12. 
Sercg.     Zwei  Falle  von  krankhafter  Selbstbesichtigung  der  Simulation.     Med. 

Klin.,  Berl.,  1916,  xii,  1100-1102. 
Serre,  Bircn  and  Brette.     Tentative  de  fraude  au  moyen  de  I'ovoalbumine  (simu- 
lation de  I'albuminurie).       Arch,  de  med.  et  pharm.  mil..  Par.,  1917,  Ix^-iii, 

935-939- 
Service  d'isolement  et  de  psychctherapie  a  la  Salpetriere  pour  le  traitement  des 

militaires  atteints   de   troubles  fonctionnels   du   systeme    nerveux.      J.   de 

med.  et  chir.  prat..  Par.,  1916,  v.  87,  pp.  90-94. 
Sfcrza,  N.     Le  sindromi  nervose  di  commozione  da  scoppio  de  granata.     'Sled. 

nuova,  Roma,  1916,  v.  7,  pp.  6-10. 
Sgobbo,  F.  P.     La  rontgenologia  causa  di  turbamento  psichico  nei  militari,  ed 

utile  mezzo  per  la  diagnosi  di  alcuni  male  simulati.     Radiol,  med.,  Torino, 

1916,  V.  3,  pp.  313-317- 
Shaikevich,  M.  O.     (Neuro-mental  disease  in  time  of  war  and  its  pre\-ention. ) 

Sibirsk.  Vrach.,  Tomsk,  1915,  v.  2,  pp.  35-39. 
Shairp,  L.  V.     The  reeducation  of   disabled   soldiers.     Am.   J.   Care  Cripples, 

N.  v.,  191 7,  V.  4,  pp.  201-21 1. 
Shangengberg,  E.     (War  injuries  affecting  the  voice  and  speech.)       Hygiea, 

Stockholm,  191 7,  v.  79,  p.  49. 
Sheehan,  R.     Malingering  in   mental  disease.     U.   S.   Nav.   M.   Bull.,   Wash., 

1916,  X,  646-653. 
Shell  explosions  and  the  special  senses.     Lancet,  Lend.,  191 5,  i,  p.  663. 
Shell  shock  and  neurasthenia.     Lancet,  Lond.,  1916,  i,  p.  627. 
Shell  shock.     Am.  med.,  Burlington,  Vt.,  1917,  v.  23,  pp.  606-607. 
Shell  shock  among  troops.     Bos.  M.  and  S.  J.,  1918,  clxxviii,  133. 
Shell  shock  patients  in  air  raids.     Brit.  M.  J.,  Lond.,  1918,  i,  p.  90. 
Shufflebotham,  Frank.     The  effects  of  military  training  upon  lead  workers. 

Brit.  M.  J.,  Lond.,  1915,  i,  p.  672. 
Shumkoff,  G.  E.     (Number  of  the  insane  In  the  war.)     Psikhiat.  Gaz.,  Petrogr., 

1915,  V.  2,  pp.  363-366. 
Shumkoff,  G.  E.      (Rapid  psychiatric  aid  in  the  war.)      Psikhiat.  Gaz.  Petro- 

grad.,  1916,  V.  3,  pp.  281-288. 
Shuttleworth,  G,     War  ?"^  insanitv.     J.  Ment.  Sc,  Lond.,  1916,  v.  62. 


970  BIBLIOGRAPHY 

Sicard,  J.  A.     Blessures  de  guerre.     Traitement  de  certaines  algies  et  acro-contrac- 

tures  rebelles  par  I'alcoolisation  nerveuse  locale.     Soc.  med.  des  Hdpitaux, 

17  decembre  191 5. 
Sicard.     Simulateurs  de  creation  et  simulateurs  de  fixation.     Simulateurs  sourds- 

muets.     Paris  med.,  1915,  v.  17  (Part,  med.),  pp.  423-428. 
Sicard.     Traitement  de   la  nevrite  douloureuse   du  median  par   ralcoolisation 

tronculaire  sus-lesionnelle.     Soc.  Med.  de  Hop.,  July  9,  1915;    Traitement 

de  certaines  algies  et  acrocontractures  rebelles  par  I'alcoolisation  nerveuse 

locale.     Ibid.,  Dec.  17,  1915. 
Sicard.     Traitement  des  nevrites  douloureuses  de  guerre  causalgies  par  ralcooli- 
sation nerveuse  locale.     Presse  med.,  juin,  1916. 
Sicard.     Examen  du  liquide  cephalo-rachidien   au   cours   des   commotions   par 

"  vent  d'explosif."     Paris  med.,  1915,  v.  17,  p.  556. 
Sicard.     Plicatures  vertebrales  par  "  vent  d'obus."     Spondyloses  et  attitudes 

vertebrales  antalgiques.     Examen  du  liquide  cephalo-rachidien.     Soc.  med. 

des  Hopitaux,  9  juillet,  1915. 
Sicard.     Spondylites  par  obusite  ou  vent  d'obus.     Attitudes  vertebrale  antalgi- 
ques.,  Bull,  et  mem.  Soc.  med.  d.  hop.  de  Paris,  1915,  v.  39,  p.  582. 
Sicard.     A  propos  du  proces-verbal  et  de  la  communication  de  MM.  Souques, 

Megevand    et    Donet    sur   I'examen    du    liquide  cephalo-rachidien  (seance 

du  29  octobre,  1915)  au  cours  des  commotions  par  vent  d'explosif.     Bull. 

et  mem.  Soc.  med.  d.  hop.  de  Par.,  191 5,  x.  s.  xxxix,  1034. 
Sicard.     L'alcoolisation  tronculaire  au  cours  des  acromyonties  rebelles  du  mem- 

bre  superieur.     Paris  med.,  1916,  v.  19,  509-512. 
Sicard.     Discussion  de  la  conduite  k  tenir  vis-a-vis  des  blessures  du  crine  —  par 

P.  Marie.     Rev.  Neurol.  Paris,  1916,  v.  29,  p.  462. 
Sicard  et  Cantaloube.     Les  oedemes  de  striction.     Soc.   med.   des  Hopitaux, 

26  mai  1916. 
Sicard  et  Cantaloube.     Les  reflexes  musculaire  du  pied  et  de  la  main  (myo-diagnos- 

tic  mecanique).     Presse  med..  Par.,  1916,  v.  24,  pp.  145-147. 
Sicard  et  Cantaloube.     Reflexes  musculaires  pedo-dorsaux.     Leur  valeur  diag- 

nostique  et  pronostique.     Soc.  de  Neurol.  3  fevrier  1916. 
Sicard,  J.  A.  Roger,  H.  and  Rimbaud,  L.     Syncinesie  d'eff^ort;  reactions  synci- 

netiques  par  choc  du  liquide  rachidien  sur  le  faisceau  pyramidal  degenere. 

Ibid.,  1917,  3.  s,  xli,  619-622. 
Siciliano.     Les  tropho-nevroses  traumatiques.     Rivista  critica  di  clinica  medica, 

Nos.  19120  et  21. 
Signorelli  e  Buscaino.     Bradicardia  e  riflesso  oculo-cardiaco  nella  dissenteria 

amoebica.     Riv.  di  patol.  nerv.  e  ment.,  191 7,  22,  487-90. 
Siege,  Max.     Typhuspsychosen  im  Felde.     Neurol.  Centralbl.,  Leipz.,  19 15,  v.  34, 

pp.  291-296. 
Silberstein,     Adolf.     Kriegsenvalidenfursorge     und     staatliche     Unfallfiirsorge. 

Wiirzb.    Abhandl.  a.   d.    Gesamt.-geb.   d.    prakt.    Med.,    1915,   v.    15,   pp. 

I 19-130,  and  pp.  135-148. 
Silberstein.     The  Royal  Orthopedic  Reserve  Hospital  at  Niirnberg,  Germany. 

Am.  J.  Cripples,  N.  Y.,  1917,  v.  4,  pp.  188-191. 
Silex,  P.     Neue  Wege  in  der  Kriegsblindfursorge.     2  Aufl.,  Berl.,  1916,  S.  Karger, 

8°. 
Silver,  D.     The  function  of  orthopedic  surgery  in  the  present  war.     Am.  J. 

Orthop.  Surg.  Bost.,  1917,  v.  15,  pp.  509-511. 
Similarity  of  War  Nevu-oses  to  Accident  Neuroses.     Brit.  M.  J.,  Lond.,  1915, 

i,  p.  1072. 
Simple  method  of  detecting  simulated  deafness.     Lancet,  Lond.,  1917,  ii,  369. 
Singer,  Kurt.     Wesen  und  Bedeutung  der  Kriegspsychosen.     Berl.  klin.  Wchn- 

schr.,  1915,  V.  52,  pp.  177-180. 
Sklyar,  N.  I.     (The  war  and  mental  diseases).     Sovrem.  Psikhiat.,  Mosk.,  1916, 

V.  10,  p.  98,  p.  157,  p.  453.  .     ,,     , 

Small,  C.  P.     Equilibrium  tests  for  aviation  recruits.     Jour.  A.  M.  A.,  1917, 

Ixix,  1078. 
Smlrkoff,  D.     Deux  cas  graves  de  nevrose  traumatique  par  contusion,  gueris  par 

la  suggestion  hypnotique.     Jour,  de  neurop.  et  psychiat.  de  S.  S.  Korsakoff, 

1916,  fasc.  2,  also  Rev.  neurol.,  P-r.,  1917,  v.  24,  p.  477. 


BIBLIOGRAPHY  97 1 

Smith,  G.  E.     Shock  and  the  soldier.     Lancet,  Lond.,  1916,  i,  pp.  813-817,  and 

_  pp.  853-857. 
Smith,  G.  E.  and  Pear,  T.  H,     Shell  shock  and  its  lessons.     Nature,  Lond.,  1917, 

V.  100,  pp.  64-66. 
Smith,  G.  E.  and  Pear,  T.  H.     Shell  shock  and  its  lessons.     19 17,  Manchester, 

L'niversity  Press. 
Smith,  Percy.     War  and  insanity.     J.  Ment.  Sc.,  Lond.,  1916,  v.  62,  pp.  815-817. 
Smith,   Percy.     Civilian   mental   disease   in  wartime.     Proc.    Roy.    Soc.    Med., 

Lond.,  1916,  V.  10,  pp.  1-20. 
Smyly,  C.  P.     Shell  shock.     Dublin,  J.  M.  Sc,  1917,  v.  142,  pp.  247-256. 
Sogenannten  funktionellen  Nervenerkrankungen  der  Kriegsteilnehmer.     Jahr- 

esb.  f.  arztl.  Fortbild,  Miinchen,  1915,  v.  6,  pp.  26-27. 
Soldats  aveugles  masseiirs.     Caducee,  Par.,  1917,  v.  11,  p.  12. 
Soldat  mendiant.     Ann.  med.  psychol.,  Par.,  1914-1915,  v.  6,  p.  527. 
Sollier,  P.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  crane  — 

par  P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  63-64.     Also  p.  473. 
Sollier.     Sur    les    accidents    nerveux    determines    par    la    deflagration   defortes 

charges  d'explosifs.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  575-576. 
Sollier.     Troubles  trophiques  osseux  dans  un  cas  d'hemiplegie  hysterique.     Lyon 

med.,  1916,  V.  125,  pp.  20-21. 
Sollier.     Impotence  fonctionnelle  d'origine  nerveuse  chez  les  blesses  de  guerre. 

Bull.  Acad,  de  med..  Par.,  1914,  v.  72,  pp.  346-347. 
SoUier.     Trois  cas  d'hemiplegie  hysterique  consecutive  a  des  lesions  craniocere- 

brales.     Lyon  med.,  1915,  v.  124,  p.  334. 
Sollier.     La  neurologie  de  guerre:  Decisions  prises  aux  trois  reunions  des  chefs 

des  centres  neurologiques.     Lyon  med.,  1916,  v.  125,  p.  339. 
Sollier.     Un  cas  de  canitie  par  commotion  et  emotion.     Lyon  med.,  1916,  v.  125, 

P-  329- 
Sollier.     Persistance    des    troubles    fonctionelles    pendant    le    sommeil.      Rev. 

neurol..  Par.,  1914-15,  v.  22^,  p.  1240. 
Sollier.     Sur  I'abolition  du  reflexe  cutane  plantaire  dans  les  paralysies  ou  con- 
tractures fonctionnelles.      Rev.   neurol,,   Par.,   1914-15,  v.  22-,   pp.    1280- 

12S3.  ...  /      . 

Sollier.      Du   diagnostic  clinique   de   I'exageration   et   de   la   perseverance   des 

troubles  nerveux  fonctionnelles.     Presse  med.,  Par.,  1915,  v.  23,  pp.  505- 

507. 
SoUier.      Statistique  des  cas  de  nevrose  dus  a  la  guerre.     Bull.  Acad,  de  med.. 

Par.,  1915,  V.  73,  pp.  682-684. 
Sollier.     Diagnostic  des   contractures  hystero-traumatiques  et  des  retractions. 

Lyon  med.,  1917,  v.  126,  pp.  93-96. 
Sollier.     Mecanotherapie   et   reeducation    motrice    au    point    de    vue    psycho- 

physiologique  et  moral.     Paris  med.,  191 7,  No.  38,  pp.  246-249. 
Sollier  et  Chartier.      La  commotion  par  explosifs  et  ses  consequences  sur  le 

systeme  nerveux.     Paris  med.,  191 5,  v.  17,  pp.  406-414. 
Sollier  and  Jousset,  Xavier.     Nevrites  nitro-phenolees.     Lyon  med.,  1917,  v. 

126,  pp.  187-192. 
Somen,  H.     La  pratique  du  massage.     Paris  med.,  1915,  v.  17,  pp.  97-103. 
Somen,  H.     Memento  de  mecanotherapie.     Paris,   1916,  J.   B.   Balliere  et  his, 

96  p.,  8^ 
Sommer,  R.     Krieg  und  Seelenleben  —  Einfiuss  des  Krieges  auf  das  normale 

Seelenleben.     Wien.  med.  Wchnschr.,  1915,  No.  40,  p.  1481. 
SoiiHe,  A.     Les  nerfs.     In  Poirier,  tome  iii,  fasc.  3. 
Souttar,  H.  S.     Some  points  in  nerve  injuries.     Brit.  M.  J.,  Lond.,  1917,  ii,  pp. 

817-820. 
Soukhanoff,  S.  A.     De  la  con\'iction  delirante  d'etre  prisonnier  de  guerre;  con- 
tribution a  I'etude  des  troubles  mentaux  provoques  par  la  guerre  actuelle. 

Ann.  med. -psychol.,  Par.,  1914-15.  v.  6,  pp.  549-557- 
SoxikhanofF,    S.    A.     Des   psychone\TOses   traumatiques   de    guerre.    Assemblee 

scientifique  des  medecins  de  I'hophal  de  Notre-Dame-des-Affliges  pour  les 

alienes  et  de  I'asile  Novoznamenskaia,  a  Petrograd,  avril  191 5. 
Soukhanoff,  S.  A.     Psychopathy  in  time  of  war.     Russk.  \'rach.,  Petrogr.,  1915, 

xiv,  800-804. 


972  BIBLIOGRAPHY 

Soukhanoff,  S.  A.     (Present  condition  of  science  concerning  traumatic  neurosis, 

questions  of  its  study  and  treatment  from  the  viewpoint  of  military  medicine.) 

Voyenno-Med.  J.  Petrogr.,  1916,  ccxlv,  med.-spec.,  24-1-272. 
Soukhanoff,  S.  A.     (Psychoneuroses  of  war  time.)     Russk.  Brach.,  Petrogr.,  1915, 

xiv,  437-442. 
SoukhanoiBf,  S.  A.     Psychopathies  de  guerre.     Assemblee  scientifique  de  I'hopital 

de  Notre-Dame-des-Afifliges  et  de  I'asile  psychiatrique  Novoznamenskaia, 

7  aout,  1915. 
Soukhanoff,  S.  A.     Symptomes  nerveux  accompagnant  I'abasourdissement  par 

Texplosion  des  obus.     Gazette  medicale  russe,  191 5. 
Soukhanoff,  S.  A.     (Psychoneuroses  of  wartime).     Russk.  Vrach.,  Petrogr.,  191 5, 

V.  14,  pp.  437-442,  pp.  800-804,  PP-  841-843. 
Soukhanoff,  S.  A.     (Influence  of  wind  contusion  on  the  central  nervous  system.) 

Russk.  Vrach.,  Petrogr.,  1915,  v.  14,  pp.  1010-1013. 
Soukhanoff,  S.  A.     (Data  on  the  question  of  psychoses  in  time  of  war).     Psikhiat. 

Gaz.,  Petrogr.,  1915,  v.  2,  pp.  160,  165,  204,  271. 
Soukhanoff,  A.  A.     (Present  condition  of  science  concerning  traumatic  neurosis, 

questions  of  its  study  and  treatment  from  the  viewpoint  of  military  medicine). 

Yoyenno-Med.,  J.,  Petrogr.,  1916,  v.  245,  med.-spec.  pt.,  pp.  241-272. 
Soulshow,  H.     Sur  la  ne\Tose  traumatique  avec  lesion  du  labyrinthe.     Gaz. 

med.  russe,  No.  35,  191 5. 
Souques,  A.     Monoplegies  hystero-traumatiques  chez  les  soldats.     Rev.  neurol., 

1914-15,  V.  222,  pp.  403-405. 
Souques,  A.     Contractures  ou  pseudo-contractures  hystero-traumatiques.     Rev. 

neurol.,  Par.,  1914-15,  v.  22^,  pp.  430-431. 
Souques,  A.     A  propos  des  contractures  hystero-traumatiques.     Rev.  neurol., 

Par.,  1914-15,  V.  22^  p.  437. 
Souques.     A.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du  crane  — 

par.  P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  p.  471. 
Souques,  A.     Sur  les  accidents  nerveux  determines  par  la  deflagration  de  fortes 

charges  d'explosifs.     Discussion  de  Vincent.     Rev.  neurol.,  Par.,  1916,  v.  29, 

pp.  585-586. 
Souques.     (Synaesthesialgia  in  certain  forms  of  painful  neuritis:   its  treatment 

by  rubber  gloves.)    Soc.  de  Neurol.,  May  6,  1915.    Rev.  Neurol.,  July,  1915. 
Souques,  A.     Areflexie  generalisee  chez  un  blesse  du  crane.     Rev.  neurol.,  Par., 

1917,  V.  33,  pp.  33-34. 

Souques,  A.  et  Megevand,  J.  Un  cas  de  camptocormie  ancienne  trait6e  et 
guerre  par  I'electrotherapie  persuasive.  Rev.  neurol.,  Par.,  1917,  v.  24, 
pp.   142-143. 

Souques,  Megevand  et  Donnet,  V.  Importance  del'analyse  precoce  du  liquide 
cephalo-rachidien  pour  le  dignostic  des  syndr6mes  cerebromedullaires  dus 
au  "  vent  de  I'explosif. "  Bull,  et  mem.  soc.  d'hop.  de  Par.,  1915,  v.  39,  pp. 
917-926. 

Souques  et  Rosanoff-Saloff,  Mme.  La'camptocormie.  Rev.  neurol.,  Par.,  1914, 
15,  v.  22,1  pp.  937-939- 

Southard,  E.  E.    Shell  Shock  and  After.     (Shattuck  Lecture.)     Bos.  M.  &  S.  J., 

1918,  clxxix,   73. 

Southard,  E.  E.  The  Training  School  of  Psychiatric  Social  Work  at  Smith 
College.  II.  A  Lay  Reaction  to  Psychiatry.  Mental  Hygiene,  II,  October, 
1918. 

Southard,  E.  E.  and  Solomon,  H.  C.    Neurosyphilis.     Boston,  191 7,  pp.  398-425. 

Souttar,  H.  S.     Points  arising  in  nerve  injuries.     Brit.  Med.  Jour.,  1917,  ii,  817. 

Spaiilding,  Edith  R.  The  Training  School  of  Psychiatric  Social  Work  at  Smith 
College.  III.  The  Course  in  Social  Psychiatr;^.  Mental  Hygiene,  II,  Octo- 
ber, 1918. 

Specht.  Sur  Psychopathologie  dor  Fahnenglucht.  Miinch,  med.  Wchnschr., 
1915,  4.  62,1  p.  267. 

Spielmeyer,  W.  Zur  Behandlung  "  traumatischer  "  Epilepsie.  Miinch.  med. 
Wchnschr.,   1915,  v.  62,  pp.  342-544. 

Spielmeyer,  W.  Zur  Behandlung  "  traumatischer  Epilepsie  "  nach  Hirn- 
schiissverletzung.     Med.  Klin.,  Bed.  u.  Wien,  v.  ii^,  p.  344. 

Spillmann.  Travaux  du  centre  neurologique  de  Nancy.  Rev.  neurol..  Par., 
1914-15.  V.  22,  p.  H91. 


BIBLIOGRAPHY  973 

SpHIimm.     Psychoses  et  psychonevroses  de  guerre.     Societe  de  Med.  de  Nancy 

1915- 
Sqtiire,  J.  Edward.     Medical  Hints.     Oxfcwd  War  Primers,  1915. 
Stasser,  M.     La  reeducation  professionnelle  de  mutiles  de  guerre.     Arch.  med. 

Beiges,  191 7,  V.  47,  pp.  236-241. 
Stankovic,   R.     Ueber  todlich  verlaufende  Tetanie.     Wien.    Klin.   Wchnschr. 

1917.  30,  1 107-8.  '' 
St.  Clair-Thomson,  W.     Functional  cases.     Discussion.     Proc.  Roy.  Soc.  Med., 

Lond.,  1914-15  (sect.  Laryngol.),  v.  8,  pp.  118-119. 
Stearns,  A.  W.     The  psychiatric  examination  of  recruits.     J.  Am.  M.  A.,  Chicago, 

1918,  V.  70,  pp.  229-231. 

Steiner.     Neurologic  _  und    Psychiatric    im    Kriegslazarett.     Ztschr.    f.    d.    ges. 

Neurol,  u.  Psychiat.,  Berl.,  191 5,  v.  30,  pp.  305-318. 
Stelzner,  H.     Aktuelle  Massensuggestionen.     Arch.  f.  Psychiat.,  Berl     1914-1=; 

V.  55,  No.  2,  pp.  365-388.  '        ^     ^' 

Sterz.     Neuritis  im  Gebiete  des  Plexus  lumbo-sacralis  und  hysterische  Abasie 

nach  Typhus.     Deutsche  med.  Wchnschr.,  Berl.  u.  Wien,  1915,  v.  iii,  p.  331. 
Stevenson,  W.  F.     A  note  on  "  wind  contusions  "  in  war.     Brit.  M.  J.,'  Lond 

1915,  ii,  p.  338. 
Stevenson,  W.  F.     Note  on  the  cause  of  death  due  to  high  explosive  shells  in 

unwounded  men.     Ibid.,  450. 
Stewart,  Purves.     Diagnoses  of  nervous  diseases  (War  neurology).     191 6,  E.  B. 

Treat  Co.,  New  York. 
Stewart,  P.  and  Evans,  Arthiir.     Nerve  injuries  and  treatment.     1916,  Oxford 

Univ.  Press. 
Steyerthal.     Die  Hysteric  im  Kriege.     Neurol.  Centralbl.,  37,  Nr.  16,  1918. 
Stiefler,  G.     Ein  Fall  von  genuinen  Narkolepsie.     Neurol.  Centralbl.,  37,  Nr.  11, 

1918. 
Stier,  E.     Dienstbeschadigung  und  Rentenversorgung  bei  Psychopathen.     Die 

militararztliche    Sachsverstandigentatigkeit   auf   dem  Gebiete   des   Ersatz- 

wesens  und  der  militarischen  Versorgung.     Erste  Teil.,  pp.  140-174,  Jena 

Fischer,  1917. 
Stier,  E.     Wie  kann  der  Entstehung  von  Kriegsneurosen  bei  der  Feldarmee  vor 

gebeugt  werden?     Deutsche  mil.  arztl,  Ztschr.,  Berl.,  191 8,  47,  60-72. 
Stier,  E.     Zur   militarischen   Beurteilung  nerv5ser   Krankheitzustande,  speciell 

der  Epilepsie.     Deutsche  med.  Wchnschr.,  Leipz.  u.  Berl.,  1916,  v.  42,  pp 

1 153  and  1190-1196. 
Stiles,  Harold  J.     Operative  treatment  of  nerve  injuries.     Amer.  Jour.  Orthop 

Surg.,  19 1 8,  xvi,  351. 
Stivers,  C.  G.     Testing  the  aviation  candidate.     So.  Calif.,  Prac,  1917,    xxxii 

169. 
Stookey,  Byron.     Gunshot  wounds  of  the  peripheral  nerves.     Surg.  Gynec.  and 

Obst.,  Chic,  1916,  v.  23,  pp.  639-656. 
Stookey,  B.     Gunshot  wounds  of  peripheral  nerves.     S.  G.  O.,  1916,  xxiii,  639. 
Stookey,  B.     Surgical  considerations  of  peripheral  nerve  injuries.     Surg.  Gynecol. 

and  Obstet.,  1918,  xxvii,  362. 
Stopford,  John  S.  B.     So-called  functional  symptoms  in  organic  nerve  injuries. 

Lancet,  Lon.,  1918,  i,  795. 
Stopford,  John  S.  B.     Pathological  diagnosis  in  gunshot  injuries  of  peripheral 

nerves.     Lancet,  Lon.,  1918,  ii,  445. 
Stopford,  John,  S.  B.     Trophic  disturbances  in  gunshot  injuries  of  peripheral 

nerves.     Lancet,  Lon.,  1918,  i,  465. 
Strain  of  War  on  the  Nervous  System.      Hospital,  Lond.,   191 7,  v.  61,  pp. 

415-416. 
Strain  of  war  on  the  nervous  system.     Hospital,  Lon.,  191 7,  Ixii,  415. 
Stransky,  E.     Einiges  zur  Psychiatric  und  zur  Psychologic  im  Kriege.     Wien. 

med.  Wchnschr.,  1915,  Ixv.,  1025-1030. 
Strasser,  Chariot.      Ueber  Unfall  und  Militarneurosen.     Cor.-Bl.   f.  Schwerze 

Aerzt.,  1917,  No.  9,  pp.  257-274. 
Strauss,   H.     Die   Balneotherapie    als    Heilfactor   bei   Kriegsverletzungen    und 

Erkrankungen.     Med.  Klin.,  Berl.  u.  Wien,  1915,  v.  iiS  p.  659,  also  Ztschr. 

f.  artzl.  Fortbild.,  Jena,  1915,  v.  12,  pp.  581-586. 


974  BIBLIOGRAPHY 

Strumpell,  A.     Ueber  Wesen  und  Entstehung  dor    hysterischen    Krankheiter- 

scheinungen.     Deutsche  Ztschr.  f.  Nervenh.,  Leipz.,  1916,  v.  55,  No.  1-3. 
Sudden  turning  grey  of  the  hair.     Lancet,  Lond.,  1915,  ii,  p.  613. 
Symonds,  C.  P.     Some  diseases  which  have  become  common  among  soldiers  in 

this  country.     IL  Hysteria.     Guy's  Hosp.  Gaz.,  Lond.,  1916,  xxx,  444-448. 
Syms,  J.  L.  M.     Hysterics  as  seen  at  a  base  hospital.     Practitioner,  1918,  ci, 

90. 
Syndromes  nerveux  provoques  par  I'eclatement  des  gros  projectiles  de  guerre. 

Rev.  gen.  de  clin.  et  de  therap.,  Par.,  191 5,  v.  29,  pp.  379-380. 
Syring.     Zur  Behandlung  der  Schadelschiisse  im  Felde.     Miinchen  med.  Wchn- 

schr.,  1915,  v.  621,  pp.  592-593- 
Szasz,  Pest  T.     Ueber  funktionelle  Horstorungen.     Wien.  klin.  Wchnschr.,  1915, 

v.  622,  p.  117,  also  pp.  818-819. 
Sztanojevits,  L.     Neurologisches  wahrend  des  Feldzunges.     Med.  Klin.,  Berl.  u. 

Wien,  1915,  v.  ii^,  pp.  1155-1156. 
Tanflyeff,  P.  I.     Paraffin  tumors,  produced  with  a  view  of  avoiding  military  ser- 
vice.    Prakt.  Vrach.,  S.-Peterb.,  1914,  xiii,  105,  120. 
Taylor,  J.  Madison.     Types  of  men  as  observed  among  recruits.     Bos.  M.  & 

S.  J.,  1918,  clxxix,  646. 
Terrien,  T.     De  quelques  troubles  visuels  consecutives  a  I'eclatement  des  obus. 

Arch,  d'ophth..  Par.,  1914-15,  v.  34,  pp.  633-650. 
Terrien,  F.     Remarques  sur  la  reeducation  des  aveugles.     Paris  m.ed.,  1916,  v.  21, 

pp.  490-493- 
Tests  for  alleged  deafness  in  exemption  claims.     N.  Y.  Med.  Jour.,  191 7,  cvi, 

324- 
Tests  for  the  Detection  of  Malingering.     Lancet,  Lond.,  1916,  ii,  pp.  80-81. 
Terrien,  F.  et  Vinsonneau.     Hemianopsies  d'origine  corticale.     Paris  med.,  1916 

(Part,  med.),  v.  19,  pp.  527-531- 
Thibierge,  C.     La  syphilis  et  I'armee.     Paris,  191 7,  Masson  et  Cie. 
Thibierge,  G.     Syphilis  and  the  Army.     Military  Medical  Manuals,  Univ.  of 

London  Press,  1918. 
Thiemann,   H.      Schadelschiisse.      Miinch.   med.  Wchnschr.,   1915,  v.  62',  pp. 

593-595- 
Thoma.      Neurosen    nach    Kriegsverletzungen.     Wien.    klin.   Wchnschr.,    19 16, 

xxix,  1412,  1509,  1541,  1574. 
Thomas,  A.     Hypertonie  musculaire  dans  la  paralysie  radiale  en  voie  d'ameliora- 

tion.     Sensations  cutanees  dans  le  domaine  du  nerf  radial,  provoquees  par 

la  pression  de  muscles  qui  recoivent  leur  innervation  du  meme  nerf.     Egare- 

ment  des  cylindraxes  regeneres,  destines  k  la  peau  dans  les  nerfs  musculaires. 

Soc.  de  Neurol.,  July  29,  1915.     Revue  Neurol.,  Aug. -Sept.,  1915. 
Thomas,  A.     La  sensibilite  douloureuse  de  la  peau  k  la  piqure  et  au  pincement 

dans  la  periode  de  restauration  des  nerfs  sectionnes  apres  suture  ou  greffe. 

Soc.  de  Neur.,  Feb.  3,  1916.     Revue  Neurol.,  Feb.,  1916. 
Thomas,  A.     (Multiple  paralyses  of  the  cranial  nerves.)     Soc.  de  Neurol.,  July  i, 

Thomas,  Andre.     Topoparesthesies  cicatricielles :  examen  des  troncs  nerveux  et 
des  cicatrices  dans  les  blessures  des  nerfs.     Paris  med.,  1916  (Part,  med.),  v. 

19.  PP-  535-537-  .  ,.,,,. 

Thomas,  Andre.     Hypermyotonie  ou  contracture  secondaire  dans  les  paralysies 

des  nerfs  peripheriques  par  blessure  de  guerre.     Paris  med.,  1916,  v.  21,  pp. 

203-209. 
Thomas,  Andre  et  Ceillier,  H.     Hemianesthesie  cerebrale  par  blessure  de  guerre. 

Rev.  neurol..  Par.,  191 7,  v.  24,  pp.  34-38. 
Thomas,  E.     Troubles  cardiaques  et  service  militaire.     Rev.  med.  de  la  Suisse, 

Rom.,  Geneve,  191 7,  v.  37,  pp.  270-283. 
Thomas,  J.  J.     Types  of  neurological  cases  seen  at  a  base  hospital.     J.  Nerv.  and 

Ment.  Dis.,  N.  Y.,  1916,  v.  44,  pp.  495-502. 
Thomas,  J.  Lynn.     Peripheral  shock  and  its  central  effects.     Brit.  M.  J.,  Lond., 

1916,  ii,  pp.  44-45. 

Thomas,  J.  L.     Death  from  high  explosives  without  wounds.     Brit.  M.  J.,  Lond., 

1917,  V.  I,  p.  599.  „         „ 
Thomson,  Campbell.     Shell  shock  without  visible  signs  of  mjury.     Proc.  Roy. 

Soc,  Med.,  Lend.,  191 5-16,  v.  9  (Neurol,  sect.),  pp.  36-37. 


BIBLIOGRAPHY  975 

Thomson,  D.  G.     A  descriptive  record  of  the  conversion  of  a  county  asylum  into 

a  war  hospital  for  sick  and  wounded  soldiers  in  1915.     J.  Ment.  Sc,  Lond., 

1916,  V.  62,  pp.  109-135. 
Thome,  Bezly.     Treatment  by  physical  methods  of  mental  disabilities  induced 

by  the  war.     Proc.  Roy.  Soc.  Med.,  Lond.,  1917-18,  v.  10  (sect.  Balneol.), 

pp.  39-41- 
Thorne,  W.  B.     The  soldier's  heart.     Practitioner,  1916,  xcvi,  551. 
Three  Cases  of  Head  Injury.     Guy's  Hosp.,  Gaz.  Lond.,  1916,  v.  30,  pp.  297- 

299. 
Tilley,  Herbert,     Two  cases  of  functional  aphonia  following  bursting  of  a  shell  in 

close  proximity.      Proc.  Roy.  Soc.   Med.,  Lond.,  1915-16,  v.  8  (Laryngol. 

sect.),  p.  155. 
Timofieyeff,  A.  V.     (Where  do  soldiers  in  the  active  army  become  insane?) 

Psikhiat.  Gaz.,  Petrogr.,  1915,  v.  2,  p.  261. 
Timofieyeff,  A.  V.     (Statistics  of  mental  diseases  in  the  active  army  in  the  present 

campaign.)     Psikhiat.  Gaz.,  Petrogr.,  1915,  v.  2,  p.  341. 
Timofieyeff,  S.  L.     (Contractures  of  the  fingers  and  toes  in  those  who  injure 

themselves  to  avoid  military  service.)     Voyenno  Med.  J.,  Petrogr.,  1915,  v. 

242,  pued.  spec,  pt.,  pp.  27-42. 
Timofieyeff,  S.  L.     (Self  inflicted  injuries  and  malingering  among  recruits  under 

observation;    according  to  data  of  the  Kiyev  military  hospital  for  191 1.) 

Voyenno.  Med.  J.,  Petrogr.,  1915,  v.  243,  pp.  591-630. 
Tinel,  J.     Les  Blessures  des  Nerfs.     Collection  Horizon,  Masson  et  Cie,  Paris, 

1917  (also  trans.  Engl.,  Phila.). 
Tinel.     Le  signe  du  "  fourmillement  "  dans  les  lesions  des  nerfs.     Presse  med., 

Oct.  7,  1915. 
Tinel,  J.     Un  cas  de  nystagmus  fonctionnel.     Rev.  neurol..  Par.,  1914-15,  v.  22^, 

pp.  490-492. 
Tinel,  J.     Paralysie  fonctionnelle  par  stupeur  musculaire.     Rev.  neurol.,  1917, 

V.  24,  pp.  500-501. 
Tobias,  E.     Ergebnisse  der  bisherigen  Kriegserfahrungen  auf  dem  Gebiete  des 

Nervensystems.     Deutsche  med.  Wchnschr.,  Leipz.  u.  Bed.,  1916,   v.    62, 

p.  ^39- 
Todd,  J.  L.     The  retraining  of  disabled  men.     Am.  Med.,  Burlington,  Vt.,  1917, 

V.  23,  pp.  380-384-  ... 
Tombleson,  J.  B.     A  series  of  military  cases  treated  by  hypnosis.     Lancet,  Lond., 

1916,  ii,  pp.  709-710. 
Tombleson,  J.  B.     An  account  of  twenty  cases  treated  by  hypnotic  suggestion. 

J.  Roy.  Army  Med.  Corps,  Lond.,  1917,  v.  29,  pp.  340-346. 
Tompkins,  E.     Stammering  in  connection  with  military  service.     Amer.  Jour. 

Pub.  Health,  1917,  vii,  638. 
Tooth,   Howard  H.     Neurasthenia  and  psychasthenia.     J.   Roy.   Army   Med. 

Corps,  Lond.,  1917,  v.  28,  pp.  329-345. 
Townsend,  R.  O.     Two  cases  for  comment.     (I)  Malingering  or  true  neurosis. 

(II)  Malingering  or  hysteria.     Practitioner,  Lond.,  1917,  xcix,  88-91. 
Traitement  de  I'anorexie  mentale.    J.  de  med.  et  chir.  prat.,  Par.,  1916,  v.  87, 

pp.  94-96. 
Treatment  of  peripheral  nerve  injimes.    Rev.  of  War  Surg.  &  Med.,  1918,  i.  No.  3, 

40. 
Treatment  of  Shell  Shock.     N.  Y.  Med.  Jour.,  1917,  cvi,  1142. 
Treatment  of  War  Psychoses.     Med.  Press  and  Circ,  Lond.,  1916;  pp.  507-508. 
Trombetta,  E.     Gli  epilettici  in  zona  di  guerra.     Gior.  d.  med.  mil.,  Roma,  19 18, 

Ixvi,  54-58- 
Trombetta,  E.     Gli  inabili  allefatiche  di  guerra.     Gior.  di  med.  mil.,  Roma,  191 7. 

Ixv,  427-436. 
Tromner.     Einen  Fall  von  lokaler  traumatischer  Hysteric.     Neurol.  Centralbl., 

Leipz.,  1915,  p.  415. 
Tromner.     Brown-Sequard-Lahmung  durch  Nackenschuss   ohne  Wirbelverletz- 

ung.     Neurol.  Centralbl.,  Leipz.,  191 5,  p.  416. 
Tromner.     (a)  Lokale  traumatische  Hysterie.     (b)  Schuss  durch  den  Hals,     (c) 

Brown-Sequard-Lahmung    durch     Nackenschuss     ohne     Wirbelverletzung. 

(Abstract)  Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41,  pp.  901- 

902. 


976  BIBLIOGRAPHY 

Tromner.     (c)    Nachweis   der   Entartungsreaktion.     (b)    Mittlere   Arm-Plexus- 

lahmung.     (c)  Blutdruck-  und  Pulsanomalien  bei  organischen  Nervenleiden. 

(d)   Halsschiisse.     (Abstract)    Deutsche  med.   Wchnschr.,   Berl.   u.   Leipz., 

1915,  V.  41,  p.  1021. 
Trotter,  Robert  H.     Observations  upon  the  condition  known  as  D.  A.  H.     Lancet, 

Lon.,  1918,  1,  371. 
Troubles  d'origine  emotive  chez  le  combattant.     Progres  med.,  Par.,  1916,  v.  31, 

P-  48. 
True,  H.     L'hemeralopie  dans  I'armee.     Montpel.  med.,  1916,  v.  39,  pp.  269-273. 
Truelle,  V.,  et  Bouderlique,  Mile.     Etat  depressif  consecutif  a  une  emotion  de 

guerre.     Ann.  med.  psychol.,  Par.,  1917,  v.  73,  pp.  595-602. 
Tsimken.     (Experimental  psychology  in  the  nature  of  an  objective  means  in  the 

diagnosis  of  malingering.)     Psikhiat.  Gaz.,  Petrogr.,  1915,  v.  i,  pp.  240-242. 
Tsiplyayefif,  P.  I.     (Simulation  of  fever,  and  measuring  of   the  temperature  in 

cadets.)     Vestnik  Obshtsh.  Hig.,  Sudeb.  i  Prakt.  Med.,  Petrogr.,  1916,  Hi, 

1277-1284. 
Tubby,  A.  H.     Cases  of  nerve  concussion  due  to  bullet  and  shell  wounds.     Brit. 

M.  J.,  Lond.,  1915,  i,  pp.  57-59- 
Tubby,  A.  H.     Bullet  wounds  affecting  the  motor  fibers  of  the  external  popliteal 

nerve.     Brit.  M.  J.,  Lond.,  1915,  i.  p.  333. 
Tuke,  Seymour.     War  and  insanity.     J.  Ment.  Sc,  Lond.,  1916,  v.  62,  pp.  818- 

819. 
TuUidge,  E.  K.     Shock  neuroses  et  psychoses  in  present  war.     Penn.   M.  J., 

Athens,  1916,  v.  19,  pp.  778-782. 
Tulloch,  A.  B.     Shell  shock.     Lancet,  Lond.,  1915,  ii,  p.  575. 
Ttuniati,  C.     La  guerison  rapide  du  mutisme  de  guerre  par  la  methode  de  Lom- 
bard.    Rev.  neurol.,  Par.,  191 7,  v.  24,  p.  475. 
Turck,  Fenton,  B.     Wound  andjshell  shock  and  their  cure.     N.  Y.  Med.  Jour., 

1918,  cvii,  901. 
Tiirk,  N.     Ueber  psychische  Storungen  bei  Verschiitteten  nach  ihrer  Belebung. 

Wien.  klin.  Wchnschr.,  1917,  v.  29,  pp.  910-913. 
Turlais.     Vent  d'obus.     Arch.  med.  d'Angers,  1915,  xix,  113-117. 
Turner,  W.  A.     Nervous  and  mental  shock;    arrangements  for  the  care  of  cases 

coming  from  overseas.     Lancet,  Lon.,  1916,  i,  1073. 
Tximer,  W.  A.     Remarks  on  cases  of  nervous  and  mental  shock  observed  in  the 

base   hospitals   in   France.     Brit.    M.    J.,    Lond.,    1915,    i,    833-835.     Also 

J.  Roy.  Army  Med.  Corps,  Lond.,  1915,  xxiv,  343-352. 
Turner,  W.  A.     Cases  of  nervous  and  mental  shock.     Brit.  M.  J.,  London,  1915, 

i,  pp.  833-835-  ,       ,  ^  ,  .  ,    ,      , 

Turner,  W.  A.  Arrangements  for  the  care  of  cases  of  nervous  and  mental  shock 
coming  from  overseas.  J.  Roy.  Army  Med.  Corps,  Lond.,  1916,  v.  27^ 
pp.  619-626;    also  Lancet,  Lond.,  1916,  i,  pp.  1073-1075. 

Turner,  W.  A.  Remarks  made  on  paper  of  Sir  John  Collie,  "  The  manage- 
ment of  neurasthenia  and  allied  disorders  contracted  in  the  Army."  "  Re- 
called to  Life,"  191 7,  Sept.,  No.  2,  pp.  251-252. 

Ttirrell,  W.  J.  Electric  treatment  of  trench  foot  and  frost-bite.  Pract.,  Lond. 
1916,  V.  96,  pp.  52-61. 

TurreU,  W.  J.  Electrotherapy  at  a  base  hospital.  Lancet,  Lond.,  1915,  i,  pp 
229-231. 

Turrell,  Sibley,  et  al.  Discussion  of  electrical  treatment  of  wounds.  Proc 
Roy.  Soc.  Med.,  Lond.,  1914-15  (Electro-therap.  sect.),  pp.  35-52. 

Turrell,  W.  J.  The  electrical  treatment  of  the  wounded.  Lancet,  Lond.,  1916 
ii,  pp.  1005-1008;  also  Am.  J.  Electrotherap.  and  Radiol.,  N.  Y.,  1917,  v.  35 
215-221. 

Uhthoff,  W.  Ueber  Kriegsblinde  und  Kriegsblinden-Fiirsorge.  Berl.  klin 
Wchnschr.,  1916,  v.  53,  pp.  78-81. 

Uhthoff.  Augenarztliche  Erfahrungen  und  Betrachtungen  iiber  Kriegsblinde 
Deutsche  med.  Wchnschr.,  Leipz.  u.  Berl.,  1916,  v.  42,  p.  1468. 

U.  S.  War  Dept.,  Stirgeon  General's  Office.  War  surgery  of  the  nervous  sys 
tem;  a  digest  of  the  important  medical  journals  and  books  published  during 
the  European  War.     Wash.,  1917,  Gov.  Print.  Off.,  360  p.,  8°. 

Urbantschitsch,  E.  Rasche  Heilung  der  Symptome  der  im  Kriege  entstandenen 
traumatischen  Neurose.     Wien.  klin,  Wchnschr.,  1916,  xxix,  1051. 


BIBLIOGRAPHY 


977 


Urstern,  M,  S.     (Mental  diseases  caused  by  the  war,  and  mental  disturbances 

caused  by  wounds  of  the  brain.)     Ruaek.  Vrach.,  Petrogr.,  1916   xv   246- 

249. 
Utili  ation  des  indisciplines  en  temps  de  guerre.     Progres  Med.,  Par.,   1916 
No.  3,  pp.  70-72.  ' 

Vachet,  tierre.  ^  Les  troubles  mentaux  consecutifs  au  shock  des  explosifs  mod- 
ernes.     Theses  de  Paris,  1915-16,  No.  15. 
Valobra,  I.     Sui  disturbi  nervosi  detti  di  natura  riflessa  in  neurologia  di  guerra. 

P^liclin.,  Roma,  1917,  xxiv,  sez.  med.,  349-370. 
Van  Schevensteen,  A.     Considerations  sur  les  conjonctivites  provoquees.     Clin. 

opht.,  Par.,  191 6,  v.  21,  pp.  595-603. 
Vaquez,  H.   and  Donzelot,  E.     L'aptitude  fonctionnelle  cardiaque  du  soldat. 

Ann.  de  med.,  Par.,  1917,  v.  4,  pp.  377-390. 
Veale,  Rawdon  A.     Some  cases  of  so-called  functional  paresis  arising  out  of  the 

war  and  their  treatment.     J.  Roy.  Army  Med.  Corps,  Lond.,  1917,  v.  29, 

pp.  607-614. 
Verdelet,    Louis.     Un    cas    de    lesion    nerveuse   traumatique.     Caducee,    Par. 

1916,  V.  16,  p.  118.  ' 

Verger,   Henri.     Abandon  de  poste  en  presence  de  I'ennemi  dans   une  fugue 

epileptique.     Jour,  de  med.  de  Bordeaux,  1915-16,  v.  45,  pp.  63-65. 
Verger,   H.^     La   notion  de  consolidation   dans   les   nevroses  traumatiques  des 

sinistres  du  travail  et  des  blesses  de  guerre.     Progres  med.,   Par.,   1916, 

V.  31,  pp.  118-122. 
Verger,  H.  et  Penaud,  R.     Les  hemiplegies  tardives  consecutives  aux  blessures 

de  la  region  cervicale.     Rev.  neurol..  Par.,  191 7,  v.  24,  pp.  281-288. 
Viets,  Henry.     Shell  shock.     J.  Am.  M.  Ass.,  Chicago,  191 7,  v.  69,  pp.  1 779-1 786. 
Viets,  Henry.     London  war  hospitals.     Boston  M.  and  S.  J.,  1917,  v.  176,  p. 

222. 
Villaret,  Maurice.     Au  sujet  des  sequelles  nerveuses  des  traumatismes  cranio- 

cerebraux  de  la  guerre  (une  statistique  de  250  cas).     Bull.  Acad,  de  med., 

Par.,  1916,  V.  76,  p.  420. 
Villaret,  Maurice.     Vingt-cinq  cas  d'astereognosie  reliquat  de  blessures  crinio- 

cerebrales?     Presse  med.,  Par.,  1916,  v.  241,  p.  56. 
Yiilaret,  Maurice.     Discussion  de  la  conduite  a  tenir  vis-a-vis  des  blessures  du 

crane  —  par  P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  458-460;    also 

P-  473- 
Villaret,  Maurice.     Propositions  de  reforme,  les  evaluations  d'invalidite  et  les 

decisions  concernant  les  militaires  atteints  de  lesions  ou  troubles  du  sys- 

teme  nerveux.     Montpel.  med.,  1916,  v.  39,  pp.  372-386. 
Villaret,  Maurice  et  Faure-Beaulieu,  M.     Les  anesthesies  corticales  a  topo- 

graphie  atypique  dans  les  traumatismes  craniens.     Paris  med.,  1916,  v.  19, 

pp.  514-518. 
Villaret,  Maurice  et  Faiire-Beaulieu,  M.     L'epilepsie  tardive  consecutive  aux 

traumatismes   de   guerre   crinio-cerebraux.     Montpel.    med.,    1916,   v.   39, 

p.  61. 
Villaret,   Maurice   et  Faure-Beaulieu,   M.     L'evolution  des  traumatismes  de 

guerre  cranio-cerebraux.     Rev.  neurol.,  Par.,  1916,  v.  24,  pp.  832-833. 
Villaret,  Maurice  et  Faiu:e-Beaulieu,  M.     Les  troubles  nerveux  tardifs  consecu- 
tifs aux  traumatismes  cranio-cerebraux  de  guerre.     Rev.  gen.  de  path,  de 

guerre,  1916,  No.  3,  pp.  213-245. 
ViUaret,  Maurice  et  Faure-Beatilieu,  M.     Le  signe  de  la  flexion  du  gros  orteil 

par  percussion  du  tendon  achilleen.     Presse  med.,  Par.,  1917,  v.  25,  531-532. 
Villaret,  Maurice  et  Rives,  A.      L'hemianopsie  en  quadrant,  reliquat  isole  de 

certaines  blessures  cranio-cerebrales.     Bull.  et.  mem.  Soc.  med.  d'  hop.  de 

Par.,  !9I5,  v.  39,  pp.  1234-1237.  .  ,     , 

Villaret,  Maurice  et  Rives,  A.      L'hemianopsie  bilaterale  homonyme  en  quad- 
rant seul  reliquat  de  blessures  graves  du  lobe  occipital.     Paris  med.,  1916, 

V.  19  (part,  med.),  pp.  20-23. 
Villaret,  Maurice  et  Mignard,  M.      Le  syndrome  psychique  residual  des  trau- 
matismes cranio-cerebraux  de  la  guerre.     Paris  med.,   1916,   (part,  med.), 

V.  21,  pp.  209-214. 
Vilvandre,  G.     Radiography  in  gunshot  wounds  of  the  skull.     Arch,  of  Radiol. 

and  Elec,  19 16,  306. 


978  BIBLIOGRAPHY 

Vilvandre,  G.  and  Morgan,  J.  D.      Movements  of  foreign  bodies  in  the  brain. 

Arch,  of  Radiol,  and  Elec,  1916,  xxi,  22. 
Vinaj,  G.  S.     La  terapie  fisica  in  tempo  di  guerra.     Idrol.  e  climat.,  Firenze,  1917, 

V.  28,  pp.  30-45- 
Vincent,  Armand  et  Wilhelm,  Andre.     Un  cas  curieux  de  blessure  du  crane  par 

eclat  d'obus.     Paris  med.,  1915  (part,  med.)  v.  17,  pp.  ii8-iig. 
Vincent,  CI.     Du  pronostic  des  troubles  nerveux  d'ordre  ref^exe.     Persistance  ou 

augmentation   des  troubles  vasomoteurs  et   de  I'amyotrophie   malgre   une 

mobilisation   active   et    prolongee   du    membre   malade.     Soc.   de    Neurol., 

Nov.  1916. 
Vincent,  CI.     Note  sur  le  traitement  de  certaines  troubles  fonctionnels.     Rev. 

neurol.,  Par.,  1916,  v.  23,  pp.  102-104. 
Vincent,  CI.     Au  sujet  de  I'hysterie  et  de  la  simulation.     Rev.  neurol.,   1916, 

V.  23,  pp.  104-107. 
Vincent,  CI.     Discussion  de  la  conduite  k  tenir  vis-a-vis  des  blessures  du  crane 

par  P.  Marie.     Rev.  neurol.,  Par.,  1916,  v.  29,  pp.  471-472. 
Vincent,  CI.     Quelques  rectifications  k  I'article  de  ^L  Rimbaud;    Sur  le  traite- 
ment des  psychonevroses  de  guerre.      Marseille  med.,    1916-17,   liii,  936- 

940- 
Vincent,  CI.     La  reeducation  intensive  des  hysteriques  inveteres.     Bull,  et  mem. 

Soc.  med.,  d'  hop.  de  Par.,  1916,  21  juillet. 
Vincent,  CI.     Sur  les  accidents  ner\^eux  determines  par  la  deflagration  de  fortes 

charges  d'explosifs.     Rev.  neurol..  Par.,  1916,  v.  29,  pp.  573-574. 
Vincent,  CI.     Le  traitement  des  phenomenes  hysteriques  par  la  "  reeducation 

intensive."     Arch,  de  med.  electr.,  Bordeaux,  1916,  v.  24,  pp.  405-416. 
Vincent,  CI.     Variations  du  reflexe  achilleen  chez  certaines  hommes  atteints  de 

troubles  physiopathiques  des  membres  inferieurs.     Rev.  neurol.,  Par.,  191 7, 

V.  24,  pp.  224-231. 
Vincent,  CI.     Sur  le  traitement  et  le  pronostic  des  phenomenes  physiopathiques. 

Rev.  neurol.,  Par.,  1917,  v.  24,  pp.  537-544. 
Vincent,  W.     Use  of  asylums  as  military  hospitals.     J.  Ment.  Sc,  Lond.,  1916, 

V.  62,  pp.  174-178. 
Viruboff,  M.  A.     (Psychoses  and  psychoneuroses  of  the  war.)     Psikhiat.  Gaz., 

Petrogr.,  19 15,  v.  2,  pp.  70-72. 
Viruboff,    M.    A.     (Organization   of   aid    to    insane    soldiers.)     Psikhiat.    Gaz., 

Petrogr.,  1915,  v.  2,  pp.  168-171. 
Viruboff,    M.    A.     (Necessity   for   constructing   hospitals   for   soldiers   suffering 

from  psychoneuroses.)     Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  p.  194. 
Viruboff,    M.    A.     (Organization    of    the    care    of    insane    warriors.)     Sovrem. 

Psikhiat.,  Mosk.,  1916,  v.  10,  pp.  19-27. 
Viry,  H.     L'instinct  genesique  et  la  guerre  actuelle.     Rev.  gen.  de  clin.  et  de 

therap.,  Par.,  1916,  v.  30,  pp.  355-357- 
Vitaut,  L.     Un  cas  d'oedeme  de  striction.     Rev.  gen.  de  clin.  et  de  therap..  Par., 

1916,  XXX,  551. 
Vlasoff,  Y.  P.     Cases  of  artificial  phlegmons  caused  by  injections  of  kerosene. 

Voyenno-Med.  J.,  Petrogr.,  1915,  ccxlii,  med. -spec,  pt.,  63-73. 
Vlasto,  Michael.     Two  cases  of  functional  aphonia.     J.  Roy.  Nav.  M.  Serv., 

Lond.,  1917,  V.  3,  pp.  113-115. 
Vogt,  H.     Die  Kriegsneurosen  (in:  Handbuch  der  Therapie  der  Nervenkrank- 

heiten,  Jena,  Gustav  Fischer,  1916). 
Vogt,  H.     Die  Neurosen  im  Kriege  (in:  Die  Kriegsbeschadigungen  des  Nerven- 

systems,  Wiesbaden,  Bergmann,  1917). 
Von  Eberts,  E.  M.     Functional  re-education  and  vocational  training  of  soldiers 

disabled  in  war.     Canad.  ^L  Ass.  J.,  Toronto,  1917,  v.  7,  pp.  193-200. 
Vorschlage  zur   Abfindung  der  Kriegsneurosen  auf   Grund  dieser  Erfahrungen. 

Med.  Cor.-Bl.  d.  Wiirttemb.  arztl.  Landesver  Stuttg.,  1916,  v.  86,  p.  42. 
Voskresenski,  M.  K.     (Brief  annual  review  of  the  activity  of  the  psychiatric 

organization  of  the  Russian  Society  of  the  Red  Cross  at  the  armies  of  the 

southwestern  front.)     Russk.  Vrach.,  Petrogr.,  v.  15,  pp.  12-16. 
Voss,  G.     Zur  Frage  der  Simulation  bei  Soldaten.     Deutsche  med.  Wchnschr., 

Berl.  u.  Leipz.,  1916,  No.  48,  pp.  1476-1477. 
Vvedenski,  I.  N.     (Cases  of  wartime  psychoses  in  children.)     So\Tem.  Psikhiat., 

Mosk.,  1916,  v.  10,  pp.  1-8. 


BIBLIOGRAPHY 


979 


Wegener.   Arbeitstheraple  und  Rentenabschatzung  bei  Kriegsneurotiker.    Neurol. 

Centralbl.,  37,  Nr.  16,  1918. 
Wagner.      Ueberblick  iiber  die  in  der  Heil-    und   Pflegeanstalt   Giessen   be- 
handelten  nerven  und  geisteskranken  Soldaten.     Munchen  med.  Wchnschr 

1916,  No.  15,  pp.  548-550. 

Wagner,  v.  Jauregg.  Nervosa  Storungen  nach  eine  oberflachliche  Verletzung  am 
Rucken  durch  Schrapnellschuss.     Wien.  klin.  Wchnschr.,  1915,  v.  28,  p.  190. 

Wallace,  Cuthbert  C.  Traumatic  shock.  Report  of  fourth  session  of  Research 
Soc.  of  American  Red  Cross  in  France.     Med.  Bull.,  1918,  i,  417. 

Wallace,  W.  Methods  of  examining  the  vision  of  recruits  and  soldiers  with 
special  reference  to  assumed  and  real  defects.  J.  Roy.  Army  Med.  Corps, 
Lond.,  1916,  V.  26,  pp.  471-489. 

Waller,  A.  D.  Galvanometric  observation  of  the  emotivity  of  a  normal  subject 
(English)  during  the  German  air  raid  of  Whit-Sunday,  May  19,  1918.  Lan- 
cet, Lon.,  1918,  I,  916. 

Walther,  Ch.  Traumatisme  de  la  region  scapulaire.  Decollement  de  I'omo- 
plate.  Paralysie  totale  du  membra  superieur  d'origine  psychique.  Bull, 
et  mem.  soc.  de  chir.  da  Par.,  1914,  v.  40,  pp.  1380-1382. 

War  and  Incidence  of  Insanity.     Med.  Officer,  Lond.,  1917,  v.  16,  Oct.  6. 

War  and  the  Incidence  of  Insanity.     Pub.  Health  J.,  Toronto,  1917,  v.  8,  p.  30. 

War  and  Insanity.     Med.  Officer,  Lond.,  1916,  v.  15,  p.  43. 

War  and  Insanity.     Hospital,  Lond.,  1917,  v.  60,  p.  5. 

War  and  Mental  Hospitals.     Med.  Officer,  Lond.,  1916,  v.  15,  p.  108. 

War  and  Nervous  Breakdowns.     Lancet,  191 5,  i,  pp.  189-190. 

War  and  the  Nervous  System.     M.  J.  Australia,  Sydney,  1916,  v.  i,  p.  205. 

War  and  Netu-oses.     J.  Am.  M.  A.,  Chicago,  191 7,  v.  67,  pp.  647-648. 

War  and  Other  Causes  of  Insanity.     Brit.  M.  J.,  Lond.,  1917,  i,  p.  301  (also 

1917,  i,  p.  310). 

War  and  Psychoanalysis.     N.  York  M.  J.,  1916,  v.  104,  p.  1251. 

War  neuroses  and  psychoses.     Mil.  Surgeon,  Wash.,  1916,  v.  38,  pp.  320,  428, 

545- 
War  Surgery  of  the  Nervous  System.     Pub.  Office  Surgeon  General,  1917. 
Watson- Williams,   P.     Functional  cases.     Discussion.     Proc.   Roy.   Soc.  Med., 

Lond.,  1914-15  (sect.  Laryngol.),  v.  8,  p.  119. 
Weber,   L.   W.     Ueber  Granatkontusion    (Gaupp).     Neurol.   Centralbl.,    1915, 

V.  34,  p.  780. 
Weber,  L.  W.     Zur  Entstehung  der  Unfallsneurosen.     Munchen  med.  Wchnschr., 

1915,  V.  62,  p.  400. 

Weber,  F.  Parkes.  Aspects  of  death  and  correlated  aspects  of  life  in  art,  epi- 
gram, and  poetry.     3rd  ed.,  London,  1918. 

Weekers,  L.  L'hemeralopie  chez  les  soldats.  Arch,  d'opht..  Par.,  1916,  v.  35, 
pp.  73-88. 

Weekers,  L.     Night  Blindness  (hemeralopia).     Med.  Press  and  Circ,  Lond., 

1916,  V.  102,  pp.  386-387. 

Weichbrodt,  R.      Einige   Bemerkungen  zur  Behandlung  d.   Kriegsneurotikern. 

Monatschr.  f.  Psych,  u.  Neurol.,  43,  1918. 
Weil,  Gaupp,  Weintrand,  Sanger,  Lilienstein.     Diskussion  iiber  Kriegserfahr- 

ungen.     Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  956-960. 
Welch,  W.  H.     Medical  problems  of  the  war.     Johns  Hopkins  Hosp.   Bull., 

Bait.,  1917,  Apr.,  p.  156. 
Wessman,     R.     Die     Beurteilung    von    Augensymptomen    bei    Hysterischen. 

Abhandl.  a.  d.  Geb.  d.  Augenh.,  Halle  a.  S.,  1916,  v.  10,  No.  1/2  also  Cor. 

Bl.  f.  Schweiza  Aerzte,  1917,  No.  6,  p.  191. 
West,  C.  E.     Special  discussion  on  warfare  injuries  and  neuroses.     Proc.  Roy. 

Soc.  Med.,  Lond.,  1917,  v.  10  (sec.  Otol.),  pp.  92-93. 
Westphal,  A.     Hysterischen   beziehungsweise    psychoganan    Hor-    und    Sprach- 

storungen  bei  Soldaten.     Med.  Klin.,  Bed.  u.  Wian,  1915,  v.  ii^,  p.  1303. 
Westphal,  A.     Ueber  Augensymptoma  in  einem  Falla  von  traumatischer  Hysteria 

(mit  Krankenvorstellung).     (Abstract)  Deutsche  med.  Wchnschr.,  Berl.  u. 

Leipz.,  1915,  V.  41,  p.  1202. 
Westphal,     A.     (a)  Hystarische    Taubstummheit    bei    Kriegsteilnehmern.     (6) 

Horstummheit.   Deutsche  med.   Wchnsche.,   Leipz.   u.    Bed.,  1915,  v.  41^ 

pp.  I 560-1 561. 


980  BIBLIOGRAPHY 

Westphal,  A.  und  Hiibner,  A.  H.     Ueber  nervosa  und  psychische  Erkrankungt., 

im  Kriege.     Med.  Klin.,  Bed.  u.  Leipz.,   1915,  v.   ii>,  pp.  381-383;    also 

pp.  413-417- 
Wexberg,    Erwin.     Indirelrte    Gehimverletzung    durch    Schadelschuss.     Wien. 

klin.  Wchnschr.,  1916,  v.  29,  pp.  418-419. 
Weyert     Militar-psychiatrische     Beobachtungen    und    Erfahrungen.     Samml. 

zwangl.  Abhandl.  u.  d.  Geb.  d.  Nerv.  u.  Geistesk.,  Halle  a.  S.,  1915,  v.  11, 

No.  2  to  No.  4,  pp.  1-145. 
Weygandt,   W.     Versorgung   der    Neurosen    und    Psychosen   im   Felde.     Med. 

Klin.,  Bed.  u.  Wien,  v.  IO^  pp.  1503-1505. 
Weygandt,  W.     Psychosen.     Berl.  klin.  Wchnschr.,  1914,  v.  51^,  p.  1949. 
"Weygandt,    W.     Geisteskrankheiten    im    Kriege.     Miinchen    med.    Wchnschr., 

1914,  ii,  V.  61,  pp.  2109-21 12. 

Weygandt,     W.        Kriegspsychiatrische     Begutachtungen.       Miinchen.     med. 
Wchnschr.,   1915,  v.   62^  pp.    1257-1259;  also  Neurol.   Centralbl.   Leipz., 

1915,  V.  34,  pp.  925-926. 

Weygandt,  W.  Kr  legs  psychosen.  Neurol.  Centralbl.,  Leipz.,  1915,  v.  34,  pp.  43-44. 
Weygandt,     W.     Psychische     Erkrankungen     bei     Soldaten.     Deutsche     med. 

Wchnschr.,  Leipz.  u.  Berl.,  1915,  xli,  540,  694. 
Weygandt,     W.     Psychose     auf     Grund     von     Hirntrauma.     Deutsche     med. 

Wchnschr.,  Leipz.  u.  Berl.,  1915,  v.  41,  p.  1354. 
Weygandt,   W.     Kriegspsychiatrische    Begutachtungen.     Med.    Klin.,    Berl.    u. 

Wien,  1915,  V.  11-,  p.  1084. 
Weygandt,  W.     Psychosen.     Berl.  klin.  Wchnschr.,  1915,  v.  52^,  p.  224. 
Weygandt,    W.     Kriegseinfliisse    und    Psychiatrie.     Jahresk.    artzl.    Fortbild., 

Miinchen,  1915,  v.  5,  pp.  15-50. 
Weygandt,      W.      Kriegspsychiatrische  Begutachtungen.      Psychiat.  —  neurol. 

Wchnschr.,  Halle  a.  S.,  191 5-16,  v.  17,  pp.  215-217. 
Weygandt,    W.     Die    Geisteskrankheiten    im    Kriege    (in    Die    Kriegsbeschadi- 

gungen  des  Nervensystems.     Wiesbaden,  Bergmann,  191 7). 
Whale,  H.  L.     Functional  aphonia.     Proc.   Roy.   Soc.   Med.,  Lond.,   1914-15, 

(Laryngol.  sec),  v.  8,  p.  117. 
White,  Ernest  W.     Shell  shock  and  neurasthenia  in  the  hospitals  in  the  western 

command;  obser\-ations.     Brit.  Med.  Jour.,  1918,  i,  421. 
White,  J.  Renfrew.     The  extent  and  nature  of  the  sensory  loss  in  musculospiral 

paresis.     J.  Roy.  Army  Med.  Corps,  Lond.,  1916,  pp.  340-353. 
White,  R.  P.     Effects  of  dinitrobenzine  and  other  nitrosubstitution  products  of 

the  aromatic  series  on  the  workmen  employed  in  the  manufacture  of  high 

explosives.      (See  Oliver's  "  Dangerous  Trades,"  p.  475.) 
White,  S.  E.     Nerv'e-strain  and  war.     Lancet,  Lond.,  1915,  ii,  1317. 
White,  W.  A.     The  state  hospital  and  the  war.     Mental  Hyg.,  Concord,  N.  H., 

1917.  i.  377-382.  _ 
Wicart.     Les  mutilations  de  I'ouie  par  les  detonations.      Comment  elles  guer- 

rissement.     Presse  med..  Par.,  1917,  v.  25,  p.  8. 
Wideroe,  S.     (Shell  shock.)     Norsk.  Tidsskr.  i  mil.,  Halsov.,  Kristiania,  1917, 

V.  21,  pp.  77-90- 
Wiener,  E.     Hitzschlag  und  Sonnensstich.     W'len.  med.  Wchnschr.,  1915,  v.  28, 

pp.  721-722. 
Wietfeldt.     Avitaminose  als  Ursache  der  Nachtblindheit  im  Felde.     Miinchen 

med.  Wchnschr.,  1915,  v.  62',  p.  1743. 
Wietung.     Leitsatze    der    funktionellen     Nachbehandlung     kriegschirurgischer 

Schaden.     Leipz.,  1915,  43  p.,  8°. 
Williams,  Frankwood  E.  and  Brown,  Mabel  W.     Neuropsychiatry  and  the  war, 

a  bibliography  with  abstracts.     Ment.  Hyg.,  Concord,  N.  H.,  1917,  v.  i, 

pp.  409-474- 
Williamson,  R.  T.     Remarks  on  the  treatment  of  neurasthenia  and  psychas- 

thenia  following  shell  shock.     Brit.  M.  J.,  Lond.,  1917,  ii,  713-715. 
Williamson,   R.   T.     Treatment   of   neurasthenia   following  shell   shock.     Brit. 

M.  J.,  Lond.,  ii,  pp.  713-715- 
Wilmanns.     Dienstbrauchbarkeit  der  Psychopathen.     Miinchen  med.  Wchnschr. 

1916,  No.  44,  p.  1558. 

Wilson,  Gordon.     Special  discussion  on  warfare  injuries  and  neuroses.     Proc. 
Roy.  Soc.  Med.,  Lond.,  1917,  v.  10  (sec.  Otol.),  pp.  91-92. 


BIBLIOGRAPHY 


981 


Wilson,  J.  G.     Effects  of  high  explosives  on  the  ear.     Brit.  Med.  Jour     1917   i 

353-  '    ' 

Wilson,  J.  G.     Further  report  on  the  effects  of  high  explosives  on  the  ear.     Brit 

Med.  Jour.,  1917,  i,  578. 
Wiltshire.     A  contribution  to  the  etiology  of  shell  shock.     Lancet,  Lond.,  1916 

i,  1207-1212.  ' 

Wind  of  the  Cannon  Ball.     Monde  med..  Par.,  1915,  v.  25,  pp.  214-217. 
Wiszwianski.     Demonstration   von    Kriegsneurosen    und    Neuralgien  besonders 

Ischias.     Fortsche.  d.  Med.,  Berl.  u.  Leipz.,  1915-16,  v.  2,  p.  24. 
Witry.     Le  centre  neurologique  et  psychiatrique  de  la  fortresse  de  Metz  en  1914. 

Ann.  med.  psychol..  Par.,  1916-17,  v.  73,  pp.  96-101. 
Wittennann,  E.     Kriegspsychiatrische  Erfahrungen  aus  der  Front.     Wien.  klin. 

Wchnschr.,  1916,  v.  29,  p.  1315. 
Wittennann,   E.     Kriegspsychiatrische    Erfahrungen   aus   der   Front.     Miinch. 

med.  Wchnschr.,  1915,  v.  62,  pp.  1164-1166;  also,  Neurol.  Centralbl.,  Leipz 

1915,  V.  34,  p.  928. 
Wohlwill.     Aphasische  Storungen  infolge  von  Kopfschussen.     (Abstract)  Deut- 
sche med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41,  p.  1603. 
Wohlwill.     Demonstration:     3    Patienten   mit    aphasischen   Storungen    infolge 

von  Kopfschussen.     Berl.  klin.  Wchnschr.,  191 5,  v.  511,  pp.  168-169. 
Wohlwill.     Sprachstorung  nach  Schussverletzung.     Neurol.   Centralbl.,   Leipz., 

.  1915,  V.  34,  p.  46. 
Woitachewsky.     Contribution  a  I'etude  de  I'hystero-traumatisme.     Rev.  Neurol., 

Par.,  191 7,  V.  24,  p.  476. 
Wolff.     Erhebliche  Sprachstorung  nach  Schussverletzung  am  Kopf.   Deutsche 

med.  Wchnschr.,  Berl.  u.  Leipz.,  1916,  No.  3,  p.  92. 
Wolfsohn,  Julian  M.     The  predisposing  factors  of  war  psychoneuroses.     Lancet, 

Lond.,  1918,  i,  pp.  177-180;   also  J.  Am.  M.  A.,  Chicago,  1918,  v.  70,  pp. 

303-308. 
Wollenberg,    R.      Lazarettbeschaftigung    und    Militarnervenheilstatte.      Deut. 

Med.  Woch.,  1915,  xli,  757. 
Wollenberg.     Psychisch-nervose    Storungen   im    Kriegszeiten.     Deutsche    med. 

Wchnschr.,  Berl.  u.  Leipz.,  1914,  v.  lo^  p.  1927. 
WoUenberg.     Nervose   Erkrankungen  bei   Kriegsteilnehmern.     Miinchen   med. 

Wchnschr.,  1914,  No.  44,  pp.  2181-2183. 
Wollenberg,  R.     Ueber  die  Wirkungen  der  Granatschiitterung.     Neurol.  Cen- 
tralbl., Leipz.,  1915,  V.  34,  pp.  922-924. 
Wollenberg,  R.     Lazarettbeschaftigung  und  Militarnervenheilstatte.     Deutsche 

med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41,  pp.  757-760. 
Wollenberg,  R.     Weitere  Erfahrungen  mit  der  Heilbeschaftigung  nervenkranker 

Soldaten.     Deutsche  med.  Wchnschr.,  Leipz.  u.  Berl.,  1916,  v.  A2,  pp.  6-7. 
Wollenberg,  R.     Zur  Lehre  von  den  traumatischen  Neurosen.     Kriegsarztliche 

Erfahrungen.     Beitr.  z.  klin.  Chir.,  Tubing. ,  1916,  ci  (Kriegschir.  Hefte  V), 

343-357. 
Wollenberg.     Zur  Vorgeschichte  du  Kriegsneurotiker.     Neurol.  Centralbl.,    37, 

Nr.  16,  1918. 
Work  in  France  and  Germany  (for  the  care  of  disabled  soldiers).     Recalled  to 

Life,  Lond.,  1917,  pp.  180-186,  3  pi. 
Wright,  Almroth  E.  (Sir)  and  Colebrook,  Leonard.     Acidosis  of  shock  and  sus- 
pended circulation.     Lancet,  Lon.,  1918,  i,  763. 
Wright,  H.  P.     Suggestions  for  a  further  classification  of  cases  of  so-called  shell 

shock.     Canad.  M.  Ass.  J.,  Toronto,  1917,  v.  7,  pp.  629-635. 
Wyroubow,  N.  A.     (Traumatic  Psychoneuroses.)     Moscow,  1915. 
Wyroubow,  N.  A.     (Contribution  a  I'etude  des  psychoses  et  des  psychonevroses, 

observees  a  la  suite  de  la  guerre.)    Gaz.  (russe)  Psychiat.  1915,  No.  5.     (Rev. 

neurol.,  Par.,  1917,  v.  24,  p.  468.) 
Wyroubow,  N.  A.     Les  alterations  de  la  voix  et  de  la  parole  dans  la  psychose  ou 

psychonevrose  par  contusion.     Rev.  neurol..  Par.,  1916,  v.  24,  pp.  312-316. 
Yealland,  Lewis  R.     Hysterical  Disorders  of  Warfare.     Macmillan,  19 18. 
Yegiazaroff,  I.  N.     (Psycho-  and  neuropathological  observations  on  the  wounded 

and  contused  in  the  present  war;   mutism  and  deaf-mutism  in  wounded  and 

contused;    demonstration  in  four  cases.)     Trudi,  Protok.  Imp.  Kavkazsk. 

Med.  Obsh.,  Tiflis,  1914-15.  v.  51,  pp.  81-83. 


982  BIBLIOGRAPHY 

Yerkes,  R,  M.     The  relation  of  psychology  to  military  activities.     Mental  Hyg., 

Concord,  N.  H.,  i,  pp.  371-376. 
Yerkes,  R.  M.     Psychology  and  national  service.     Psychol.   Bull.,  Princeton, 

N.  J.,  and  Lancaster,  Pa.,  1917,  v.  14,  pp.  259-263;  also  Science,  N.  Y.,  and 

Lancaster,  Pa.,  1917,  v.  46,  pp.  101-103. 
Yijrman,   N.   A.     (Neurasthenic   psychoses  in  time  of   war).     Psikhiat.   Gaz., 

Petrogr.,  1915,  v.  2,  pp.  139-142. 
Zade,  M.     Ueber  Blendungserscheinungen  im  Felde.     Miinchen  med.  Wchnschr., 

1915,  V.  62,  pp.  1514-1515. 
Zadek,    J.     Lahmungen   nach   Typhus.     Deutsche   med.    Wchnschr.,    Berl.    u, 

Leipz.,  1915,  V.  412,  pp.  1033-1034. 
Zakharschenko,  M.  A.     Un  nouveau  syndrome  dans  les  contusions  aeriennes. 

Gaz.  (russe)  Psychiat.,  1915,  No.  4.     Rev.  neurol.,  Par.,  1917,  v.  24,  p.  468. 
Zakharschenko,  M.  A.      (New  symptom  in  wind  contusion).      Psikhiat.  Gaz., 

Petrogr.,  1915,  v.  2,  pp.  56-59- 
Zakharschenko,  M.  A.     (The  clinical  picture  of  disturbances  of  speech  in  those 

suffering  from  contusion,  in  connection  with  the  question  of  air  contusions). 

Psikhiat.  Gaz.,  Petrogr.,  1916,  v.  3,  pp.  369-372. 
Zalkind,  A.  B.     (Nervous  diseases  of  war  time).     Psikhiat.  Gaz.,  Petrogr.,  1916, 

v.  3,  pp.  76-78. 
Zange,    Johannes.     Ueber    hysterische    (psychogene)    Funktionsstorungen    des 

nervosen  Ohrapparats  im  Kriege.     Miinchen  med.  Wchnschr.,  1915,  v.  62^, 

pp.  957-961. 
Zange,    Johannes.     Hysterische    Horstorungen    im    Kriege.     Deutsche    med. 

Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41*,  p.  843. 
Zange,  Johannes.     Die  organischen  Schadigungen  des  nervosen  Ohrapparates  im 

Kriege.     Deutsche  med.  Wchnschr.,  Berl.  u.  Leipz.,  1915,  v.  41^,  p.  994. 
Zangger.     Welche    medizinischen    Erfahrungen    bei    Katastrophen    konnen    im 

heutiger  Kriege  verwertet  werden?     Cor.  Bl.  f.  Schweiz.  Aerzte,  191 5,  v.  45, 

pp.  190-191. 
Zangger,  H.     Zur  Frage  der  traumatischen  Neurose.     Zentralbl.  f.  Gewerbehyg., 

Berl.,  1916,  v.  4,  p.  10;   pp.  25-32. 
Zanietowski,  J.     Die  moderne  Elektromedizin  in  der  Kriegstherapie.    Wien.  klin. 

Wchnschr.,  1915,  v.  28,  p.  805,  p.  810,  p.  838. 
Zimmem,  A.     Quels  enseignements  nous  fournit  la  reaction  de  degenerescence 

dans  les  blessures  des  nerfs.     Presse  med.,  April  15,  1915. 
Zimmem,  A.  et  Logre,  B.     Sur  le  reflexe  galvano-psychique.     Rev.  neurol.,  Par., 

1917,  V.  24,  pp.  565-567;   also  Jour,  de  Radiol,  et  d'Electrol.,  v.  2,  No.  10, 

1917,  juillet-aout,  p.  610. 
Zimmem,  A.  et  Logre,  B.     Sur  le  reflexe  galvano-psychique.     Presse  med.,  Par., 

1917.  V.  25,  p.  414.  ^  „      .  .  ,. 

Zimmem  et  Perol.     Electrodiagnostie  de  guerre.    Collection  Honzon,  Masson  et 

Cie,  1917. 
Zoroastroff,   A.  V.     (Malingering  with  a  view  to  avoiding  military  service). 

Voyenno-Med.  J.,  Petrogr.,  1915,  v.  243,  pp.  473-475. 
Zuccari,  G.     Alcuni  casi  di  psicosi  da  guerra.     Riv.  di  psicol.,  Bologna,   1916, 

V.  12,  pp.  129-140. 
Zunahme  geistiger  Erkrankungen,  Die  behauptete,  bei  Beginn  des  Kriegs  in  der 

Zivilbevolkern    Deutschlands    (Ergebnis  einer  Umfrage).     Psychiat  .-neurol. 

Wchnschr.,  Halle,  1915,  v.  17,  pp.  167-170. 


INDEX 


INDEX 


Abderhalden  test,  219. 

Abdominothoracic  tetanus,  Case  403. 

Aboulia,  719. 

Abrahams,  639,  640,  769,  Case  236. 

Accommodation  paresis,  612. 

Acrocontracture,  Cases  235,  428,  486, 
489,  529  (bayonet  clutch),  530. 

Acroparalysis,  Cases  250,  428. 

Acroparesthesia,  845,  Case  132. 

Acoumeter,  809. 

Addison's  disease,  239. 

Adiadochokinesis,  301. 

Adrenalin,  229,  239,  689. 

Adrian  and  Yealland,  674,  702,  797, 
Cases  563,  564. 

Ageusia,  375. 

Agoraphobia,  260,  763. 

Agraphia,  Cases  220. 

Aime,  672,  689. 

Albumin  in  spinal  fluid,  280. 

Albuminuria,  question  of  hysterical,  535. 

Alcohohsm  (see  Pharmacopsychoses,  dip- 
somania), 58,  113-130,  459,  589,  668, 
768,  800,  874,  Cases  86-97,  Bib.,  907, 
910,  912,  964. 

Alcoholism,  experimental,  118. 

Alexia,  161. 

Alquier,  196. 

Amaurosis  (see  Ophthalmology). 

Amblyopia,  374,  609-610.     Bib.,  959. 

Amentia,  360. 

Amnesia,  303,  392,  435,  441,  444,  453, 
462,  467,  477,  487,  488,  492,  499,  634 
(recurrent),  635,  676,  734,  739,  757,  828. 
Bib.,  932,  955,  958,  968. 

Amnesia,    in   malaria,  Case  129.     Bib., 

923- 
Amyotrophy,  719,  761. 
Analgesia,  252,  253,  483,  567. 
Anaphylaxis,  114,  329,  414,  464. 
Anemia,  capillary,  265. 
Aneroid,  275. 


Anesthesia,  253,  262,  277,  292,  320,  452, 

483,  498,  538,  544,  568,  575,  577,  685, 

744,    771,    783,    800,    824,    827,    872. 

Bib.,  918,  961. 
Anesthesia,  corneal,  in  normal  persons, 

610. 
Anesthesia  en  lunettes,  610. 
Anesthesia,  reeducation  of,  568. 
Anesthesia,  sexual  par^s,  531,  533. 
Ankle-jerk,  585.  Bib.,  906,  916. 
Ankylosis,  Bib.,  925. 
Anonymous,  Case  481. 
Anorexia,  Bib.,  975. 
Anosmia,  301,  580. 
Antagonist  muscles,  353,  355,  545. 
Antagonist  muscles  in  contraction,  350. 
Antalgic  reaction,  525. 
Anterior  horn  cell  shock,  526. 
Antebellum     experiences     repeated     in 

shell-shock  hysteria,  876,  Cases  286- 

301,  397,  532,  537,  576. 
Antityphoid  inoculation,  842,  Cases  65, 

180,  303. 
Anuria,  535. 
Anxiety  neurosis,  no,  260, 457.  Bib.,  910, 

924,  925,  927,  963. 
Aphasia,   159-161,  874,  Case  103,  Bib., 

910,  928,  929,  950,  961,  981. 
Aphasia,    hysterical,    non-existent,    454, 

766. 
Aphonia,  370,  725,  727,  816.     Bib.,  931, 

932,  940,  953,  957,  959,  9^3,  975,  978, 

980. 
Apoplexy,  Bib.,  936. 
Apraxia,  Bib.,  928,  936. 
Aprosexia,  487,  632,  637. 
Argyll-Robertson  sign  inverted  (Sollier), 

612 
Arinstein,  716,  746.     Cases  212,  249,  551, 

554,  555,  588. 
Amoux,  270. 
Armstrong-Jones,  526. 


INDEX 


Arrangement  of  cases  (see  Shell-shock, 
general  arrangement  of  cases). 

Arteriosclerosis,  225,  866.     Bib.,  919. 

Arthritics,  231. 

Arthritis,  325. 

Association-experiment,  Bib.,  927. 

Association  of  hysterical  and  other  symp- 
toms (see  passim),  522,  523,  especially 

530-534. 

Association  of  hysteric,  reflex,  and  or- 
ganic conditions,  605. 

Astasia-abasia,  282,  312,  362,  Cases  246, 
247,  348,  402,  512,  533,  569,  576. 
Bib.,  934,  973- 

Asymmetry  of  reflexes,  chloroform,  594. 

Athanassio-Benisty,  540,  556. 

Athetosis,  876,  Case  113. 

"  Atmosphere  of  cure,"  728. 

Atrocities,  860,  Cases  94,  95. 

Atrophy,  "  reflex,"  545. 

Aura,  98,  626. 

Autobiographical  statements  of  soldiers, 
Cases  121,  209,  216,  217,  226,  227,  341, 
344,  361,  364,  463,  527,  528,  575. 

Autocritique,  63. 

Autofixity,  369. 

Autognosis,  702,  859,  901. 

Autokratow,  9,  469. 

Automatism,  431,  734. 

Autopsies,  Cases  110,  118,  133,  197,  198, 
199,  200,  201. 

Auto-suggestion,  frontispiece,  95,  98,  109, 
153,  395,  498,  543,  577,  674,  738,  748. 

Aviation  (see  also  Otology),  275,  489, 
823.  Bib.,  907,  930,  938,  945,  959, 
960,  964,  970,  973 

Babinski,  157,  395,  401,  454,  456,  469, 
481,  491,  498,  535,  543,  544,  554,  563, 
566,  568,  569,  576,  578,  603,  604,  605, 
643,  647,  671,  723,  746,  748,  788,  819, 
833,  848,  856,  857,  871,  S74,  877,  878, 
891,  896,  Cases  871,  877,  878,  891,  896. 

Babinski  reflex,  280. 

Babinski-Weil  test,  621. 

Babinski  and  Froment,  389,  390,  585, 
607,  608,  69s,  696,  717,  719,  742,  787, 
Cases  274,  275,  276,  422-426. 

Babonneix  and  Celos,  Case  145. 

Babonneix  and  David,  Cases  16,  17,  30. 

"  Bait  "  for  hysteria,  544. 


Baldwin,  374. 

Ballard,  675,  689,  736,  840,  Cases  82-84. 

Ballet,   465,    554,   643,    Cases  267,   396, 

407. 
Ballet  and  de  Fursac,  404,  472,  675. 
Barany,  624.  Bib.,  907,  909. 
Barat,  Case  75. 

Batten,  Cases  113,  222,  227,  589. 
Battle  hypnosis,  638. 
Beaton,  9,  Case  5. 
Bechterew,  342. 
Beck,  Case  439. 
"Bends,"  275. 
Benisty,  331. 

Bennati,  414,  Cases  186,  221,  320,  336. 
Benon,  633. 

"Bent-back"  (see  Camptocormia) . 
Berard,  118,  696. 
Bergonie,  790. 
Bernheim,  95,  740,  902. 
"Big  belly"  (see  Pregnancy,  hysterical). 
Bilateral  symptoms,  362. 
Binswanger,  Cases  179,  217, 220,  229,  233, 

239,  309,  327,  368,  483,  505,  549,  575, 

576,  577,  579,  587. 
Biological  principles  and  neuroses.  Bib. 

915- 
Birdlike  movements,  487,  632,  637. 
Birnbaum,  222. 
Bispham,  644. 
Bladder,  276,  284,  294. 
Blassig,  Case  264. 

Blepharospasm,  Case  211.     BiB.  931. 
Blepharospasm,  372,  374. 
Blin,  Case  131. 
Blindness,  Cases  29,  208-272,  296,  297, 

433,  517,  521,  537,  538.     BiB.,  915,  921, 

928,  935,  943,  952,  958,  974,  976. 
Blindness,  cortical.  Case  105. 
Block  (see  Inhibition). 
Blood,  buffer  salts,  640. 
Blood  pressure  high,  497.     Bib.  232. 
Blood  pressure  low,  225,  228,  231,  239, 

260,  690,  851.     Bib.  232. 
Blum,  661. 
Bolshevist,  249. 
Bonhoeffer,  31,  82,  83,  222,  700,  Cases  54, 

55,  57,  65,  58,  70,  71,  76,  147,  155,  158, 

340. 
Bonnet's  sign,  452. 


INDEX 


Boschi,  704,  716. 

Boucherot,  36,  Cases  6,  18,  86,  149,  163. 

Bouquet,  Case  419. 

Bourgeois  and  Sourdille,  620,  623,  809. 

Brachial  plexus  palsy,  353,  566,  611. 

Brachial  symptoms  (see  Monoplegia). 

Brain  abscess,  Case  110. 

"Brain  fag,"  104. 

Brain  injur>^,  67,  265,  270.     Bib.  915. 

Brain  tumor.     Bib.  919  (third  ventricle). 

Brasch,  41,  689. 

Bravery,  psychopathic,  859,  Case  36. 

Briand,    Case   1,   40,    43,    99,    100,    101, 

102. 
Briand  and  Haury,  Cases  98,  467. 
Briand  and  Kalt,  Case  461. 
Briand  and  Philippe,  683,  Case  578. 
Broca,  160-161. 
Bronchopneumonia,  845. 
Brown,  412,  470,  901,  Cases  496. 
Brown-Sequard,  89,  528,  555,  843. 
Bruce,  716,  724,  769,  Cases  521,  553. 
Bvdbar  sjmdrome,  Bib.  910. 
Burial,  334,  349,  373,  393,  396,  405,  419, 

435,  457,  499,  5i2,  573,  682,  696,  698, 

768,  779,  796,  814,  819. 
Bur}^,  228. 
Buscaino  and  Coppola,  205, Cases  34, 188, 

189,  190,  370. 
Butenko,  222. 
Buzzard,  668  (chart),  791,  Cases  380,  381, 

513. 

Caisson  disease,  275. 

Campbell,  A.  W.,  669. 

Campbell,  H.,  373,  704. 

Camptocormia,  525,  529,  Cases  242-245, 

322,  385,  401,  572,  584.     Bib.  938,  950, 

951,  956,  965,  972- 
Canities,  Cases  211,  212,  540.     Bib.  943, 

971,  974- 
Cargill,  Case  418. 
Carlill,  Case  130. 
Carlill,  FHdes,  Baker,  Case  2. 
Cassirer,  Case  398. 
Cataleps}',  local,  544,  551,  552.  Bib.  916 

(post  mortem),  942. 
Catatonia,  485.     Bib.  928. 
Catiemophrenosis,  479. 
Cauda  equina,  533,  540. 


Causes    (see     Shell-shock,    nature    and 

causes). 
Cellulitis,  764. 
Celluloid  obturators,  813. 
Central  gyrus  lesions,  160. 
Cephalad    arrangement    of    SheU-shock 

cases,  852. 
Cephalea,  490. 

Cerebellar  symptoms,  Cases  375,  398. 
Cerebellum,  268,  296,  300. 
Cerebrospinal  fluid  (see  Spinal  fluid). 
Cerumen,  813. 
Cestex,  366. 

Chaplin,  Charlie,  672,  894. 
Character   (see  also  Psychology).     Bib. 

921. 
Charcot,  348,  454,  531,  544,  545,  569,  572, 

6x8,  719,  especiallj'  744  and  833,  848, 

867,  891. 
Charon  and  Halberstadt,  Case  318. 
Charpentier,  608,  696. 
Chartier,  Case  257. 
Cha\-igny,  115,  223,  275,  460,  487,  568, 

637,  656,  680,  723,  738,  740,  886,  Cases 

198,  400,  446. 
Chemical   warfare,   321,    574,    799,    889, 

Cases  215,  216,  232,  284,  314,  318,  360, 

367,  452,  586.     BiB.  956,  962,  969,  980. 
Children  (deUnquent  and  the  War).    Bib. 

923,  943- 

Chloroform  (Babinski's  experiments),  380, 

388,  545,  554,  especially  592-597,  608. 

Chorea,  421,  Cases  14,  224,  300.     Bib. 

924,  933- 

Chromatolysis   of   nerve-cells,   265,   884, 

885. 
Cintrage  (see  Camptocormia). 
Ci\'ihans,  psychiatry  of,  Bib.  915,  924, 

952,  953,  965,  981,  982. 
Clarke,  Cases  67,  394. 
Clarke,  Michell,  701. 
Claude,  693,  979,  Cases  560,  561,  573. 
Claude,  Dide,  and  Lejonne,  509,  Case  331. 
Claude  and  Lhermitte,   275,   Cases  120, 

200,  214,  375. 
Claude,  Lhermitte,Vigouroux,  Case  159. 
Claustrophobia,  Case  182.    Bib.  964. 
Clavus  hystericus,  349. 
Claw  foot,  698. 
Clunet,  456. 


INDEX 


Colchicum,  239. 

Colin  and  Lautier,  260,  Cases  32,  196. 

Colin,  Lautier,  Magnac,  46. 

Collie,  Cases  458,  472. 

Commotio    cerebri  (see  also  Brain),  134, 

260,  366,  490,  524,  699,  888. 
Commotio  spinalis,  335,  528-534. 
Compensation  (see  also  Simulation),  14, 

28, 482,  666,  837,  Cases  3,  7,  8,  22.   Bib. 

910,  911,  912. 
Concussion  deafness,  364. 
Conditioned  reflex,  445, 467,  495,  530, 613, 

622. 
Confusion,  483,  484,  487,  492,  509,  637. 

Bib.  916,  925,  948,  954,  963- 
Consiglio,  36,  Cases  63, 150, 180, 191,  367. 
Constriction   edema  (see  also  (Edema), 

569- 

Contracture,  282,  318,  525,  529,  545,  569, 
Cases  489-493  (Treatment  by  induced 
fatigue)  and  passim.  Bib.  921,  926, 
933,  939.  944,  947,  956,  962,  963,  971, 
972. 

Contrecoup,  873,  887,  Case  103. 

Conversion-hysteria,  405,  823. 

Convulsions,  706,  759,  762,  820  (see 
Hysteria,  Epilepsy).     Bib.  941. 

Convulsions  after  inoculation,  Cases  63, 
65. 

Corpse-contacts,  262,  375,  467,  476,  491, 
716  (no  redeeming  feature). 

Cortical  blindness,  Case  105. 

Cottet,  Case  132. 

Coughing,  425. 

Courtois-Sufht  and  Giroux,  164. 

Crabtree,  759. 

Craig,  644,  716. 

Crampusneurose,  409,  588.     Bib.  968. 

Cranial  nerves,  378. 

Crile,  269. 

Criminality  (see  also  Medico-legal,  Simu- 
lation, etc.).    Bib.  920,  921. 

Crises  (see  Emotional  crises),  548. 

Crouzon,  373,  851,  Cases  177,  433. 

Crutch-paralysis,  324,  605,  833. 

Cycloth)Tnoses  (Manic-Depressive 

group),  865-867,  Cases  163-169. 

D.A.H.  (see  Soldiers'  heart). 
Damaye,  153,  896. 


Dawson,  Case  552. 

Deaf-mutism,  362,  405,  767,  815,  Cases 
497-499,  514,  515,  517,  552,  557,  568, 
580,585,588.     BiB.  911,  914,  937. 

Deafmutism,  cure,  672, 681,  721,  734,  775, 
776,  781.     Bib.  925, 946,  948,  950,  960, 

965- 
Deafness,  813,  888,  Cases  259-267,  514, 

616,  622.     (See  also  Otology),  Bib.  913, 

915,  916,  917,  924,  927,  932,  933,  937, 

942,  945,  954,  962,  974,  979- 
Death,  delusion,  405. 
DeBrun,  Case  129. 
Decubitus,  285,  527,  533. 
DeFursac,  Case  302. 
Dejerine,  528,  538,  648,  740,  819,  886,  gcxs, 

901,  Cases  288,  289,  412. 
Dejerine  and  Gascuel,  Case  143. 
De  la  Motte,  Cases  152,  234. 
Delherm,  Cases  431,  432. 
Deliria  (see  also  Oniric),  488.     Bib.  919, 

924,  925,  929,  942,  971- 
DeUrium,  oniric  (see  Oniric  delirium). 
Delusions,  influenced  by  war,  214, 702,863. 
DeMassary  and  Du  Sonich,  Case  14. 
Dementia  praecox  (see  Schizophrenoses), 

861,   Cases  147-162.     Bib.  935,  939, 

957,  958. 
Denechau  and  Matrais,  479. 
Dentistry  (see  teeth). 
Depressions    (see   also   Cyclothymoses), 

714. 
Dercum's  disease,  846,  Case  141.  Bib.  936. 
Dermatology,   331,   358,   361,   362,    535 

(see  also  Hypertrichosis).     Bib.  914, 

921,  922. 
Desertion,  Cases  1,  12,  45,  52,  66,  58,  83, 

90,  92,  149,  150.     BiB.  923,  924. 
Determination  of  symptoms  to  parts  of 

body,  459,  359,  360,  362. 
Diabetes  mellitus,  846,  Case  140. 
Diagnosis,  delimitation,  834-847. 
Diagnosis  per  exclusionem  in  ordine,  847, 

,871. 
Diagnosis,    Shell-shock,    differentiation, 

871-880.     Bib.  923. 
Diagnosis:   Shell-shock,  2,  3,  Cases  371- 

422  and  passim.     Bib.  942. 
Diathermia,  166,  607,  896. 
Dichroism,  spinal  fluid,  283. 


INDEX 


Dide,  456. 

Dietotherapy,  476,  674,  675,  701. 

Dieulafoy,  373,  609. 

Diphtheria,  845,  Cases  127,  128.     Bib. 

931,  953,  962. 
Diplegia,  facial,  Bib.  909,  958. 
Diplopia,  monocular,  427,  613,  827. 
Dipsomania,  Bib.  917. 
Disciplinary  (see  Medicolegal). 
Disgust  (see  also  Corpse-contacts),  262, 

375,  467,  476,  491,  519,  855. 
Dissociation  of  personality,  Case  369. 
Dissociation  of  sensations,  570. 
"Doll's  head"  anesthesia,  744. 
Donath,  Cases  20,  306,  362. 
Dubois,  716,  740,  819. 
Dreams,  hunger  and  thirst,  475. 
Dreams,  smell,  476. 
Dreams  (see  also  Oniric  delirium),  470, 

477,  503,  582,  713,  716,  728,  732,  756. 

Bib.  947,  955. 
Dromomania  (see  also  Fugue),  Case  191. 
Duco  and  Blum,  Case  22. 
Dumas,  637. 

Dumesnil,  Cases  167,  168,  185. 
Dumolard,  Rebierre,  QueUien,  Case  110. 
Dupouy,  Cases  161,  300,  377. 
Duprat,  896,  899,  Cases  51,  346,  442,  443. 
Dupre,  437,  459. 
Dupr6s  and  Rist,  Case  292. 
Duret  and  Michel,  273. 
Duvernay,  554,  Case  486. 
D)mamopathic,  856,  871. 
Dysarthria,  159,  356. 
Dysbasia  (see   passim),  560,  Cases  248, 

278;  especially  397-400;  537,  547,  560, 

561.     Bib.  941. 
Dysentery,  586,  705. 
Dysentery,  psychosis,  Case  122. 
Dyskinesia,  633. 
Dysmnesia,  637. 

Ear,  injuries  of  (see  also  Otology),  Bib. 

929,  932,  937,  940,  943,  948,  949,  955, 

957,  962,  981. 
"  Earthquake  hysterias,"  881. 
Ecmnesia,  438. 
Eczema,  429. 
Edema,  hysterical,  535,   569,  646,  663. 

Bib.  909,  942,  943. 


Eder,  702,  740,  750,  891,  Cases  178,  296, 
359,  529,  544. 

Edinger,  414. 

"Effectives,"  military,  56,  161. 

Elective  exaggeration  of  reflexes,  380  (see 

Physiopathic). 
Electrotherapy  (see  also  Treatment,  psy- 

choelectric),  Bib.  916. 
EUiot,  Cases  210,  237. 
Embolism  (see  Fat,  Gas). 
Emotion,  266,  348,  413,  539,  559,  582, 

589,  63s,  679,  701,  706,  713,  735,  (B 

group,   emotional,   Myers),    808,   900. 

Bib.  909,  919,  920,  923,  926,  939,  941, 

944,  947,  948,  954,  955,  958,  963,  964, 

965,  968,  976,978. 
Emotion  and  epilepsy,  97,  413,  Cases  85, 

302. 
Emotional  crises,  453,  455. 
Emotional  factors  absent.  Case  239. 
Emotional   shock.    Cases   334-339,   343. 

Bib.  928. 
Encephalitis  (alcoholic?),  459. 
Encephalopsychoses  (focal  brain  group  of 

mental  diseases),  490,  Cases  103-121. 
Enterospasm,  Bib.  928. 
Enuresis,   70,   252,   Cases  51,  61.     Bib. 

964,  967. 
Epilepsy,  see  Epileptoses. 
Epilepsy,  "affect,"  97. 
Epilepsy,     Brown-S6quard's,    Case     69. 

Bib.  947. 
Epilepsy,  hysterical,  treatment  of,  628. 

Bib.  938. 
Epilepsy  and  inoculation    (see   Convul- 
sions). 
Epilepsy,  Jacksonian,  158,  Cases  66,  105, 

441  (hysterical),  547  (same).     Bib.  916, 

922,  925,  938,  944,  965- 
Epilepsy,  larvata,  73,  Case  81. 
Epilepsy,  late,  93. 
Epilepsy,  pleural,  187. 
Epilepsy,  "reactive,"  70,  102,  Cases  57, 

70,  76.     Bib.  933. 
Epileptic  equivalents,  112,  488,  490. 
Epileptoses  (Epileptic  Group),  675,  699, 

839-843,  Cases  53-85.    Bib.  905,  910, 

911,  937,  938,  939,  945,  947,  956,  961, 

968,  972,  973,  975,  977. 
Equilibrium- tests  (see  Otology). 


8 


INDEX 


Erb's  palsy,  598. 

Ereutophobia,  432. 

Erichsen,  544. 

Erythromelalgia,  Bib.  916. 

Eschars,  285. 

Eschbach  and  Lacaze,  Case  108. 

Espionage,  126,  201. 

£,lals  commotionncls,  832. 

Elats  emotionnels,  832. 

JEtats  seconds,  72,  108,  530. 

Etiology  (see  Shell-shock,   Nature    and 

causes). 
Ether  versus  chloroform,  769. 
"Excommunication"  by  inhibition,  369, 

403- 
Exhaustion,    102,    228,    469,    482,    689, 

699. 
Experimental  work,  294. 
Explosive  diathesis,  700. 
Explosives,  high,  115,  266,  294,  295. 
Exposure,  519,  Case  239. 
Eye  (see  also  Ophthalmologj-),  Bib.  932, 

934,  940,  941,  962,  964. 
Eye,  functional  cases,  Cases  432-437. 
Facial  paralysis,  530. 
Facial  spasm,  Case  306. 
Fades,  deafmutism,  815. 
Faradism    (see    Treatment,    Shell-shock 

neuroses,  Psychoelectric). 
Farrar,  Case  8. 
Fat  embolism,  24. 
Fatigue,  225,  231,  375,  448,  469,  498,  502, 

557,  639>  689,  708,  85s,  900.    Bib.  907, 

924,  929,  931,  937,  941,  943,  948,  964, 

975- 
Fatigue,  induced  (see  Treatment). 
Fauntleroy,  275. 

Fear,  64,  223,  258,  338,  375,  404,  425, 
440,  441,  451,  466,  519,  67s,  855-  Bib. 
907,  958. 

Fearnsides,  12. 

Feeblemindedness,  857,  Cases  35-52. 

Feebleminded,  of  use  in  army,  48,  Cases 
35,  37,  41. 

Felling,  750,  775,  Case  369. 

Ferrand,  390,  Case  567. 

Finger-prints,  Bib.  916. 

First  name  extraordinary,  Case  48. 

Fluorescein  test,  372. 


Focal  brain  lesions  with  mental  disease, 

Cases   103-121    (see   also   under   En- 

cephalopsychoses) . 
Foix,  159. 
Formulae  of  Shell-shock,  4,  5,  chart  2 

(page  6),  chart  3  (page  7). 
Forster,  348,  349. 
Forsyth,  702,  Cases  286,  297 
Foucault,  405,  561. 
Fractures,  Bib.  906.  , 

Eraser,  364. 
Freud,  39,  702,  716. 
Friedmann,  843,  Case  77. 
Friedreich's  disease,  551. 
Froment    (see   also   Babinski    and   Fro- 

ment).  Case  203. 
Fugue  a  deux,  235. 
Fugue,  alcoholic,  841,  Case  88. 
Fugue,  catatonic,  202,  Case  149. 
Fugue,  emotional.  Cases  43,  52,  75. 
Fugue,  epileptic,  72,  841,  Cases  53,  61, 

62,  75.     Bib.  977. 
Fugue,  hysterical,  850,   Cases  171,  173, 

368,  444. 
Fugue,  melancholic,  Case  164. 
Fugue,  obsessive.  Case  445. 
Fugue    and    oniric    delirium,    471,    569. 

Bib.  914,  917,  948. 
Furloughs,  685.     Bib.  919. 

Gaillard,  Case  137. 

Gait  disorder  (see  Astasia-abasia,    Dys- 

basia) . 
Gallavardin,  641. 
Galvanism,  (see  Treatment,  Shell-shock, 

Neurosis,  Psychoelectric). 
Ganser  symptom,  212,  213. 
Garel,  723,  Case  581. 
Gas  embolism,  270. 
Gassing  (see  Chemical  warfare). 
Gastro-enterology  (see  Stomach). 
Gastropaths,  400. 
Gaucher  and  Klein,  Case  313. 
Gault's  cochleopalpebral  reflex,  624. 
Gaupp,   Cases  226,  259,  317,  334,  353, 

359,  449,  469. 
Gayet,  26. 
General  paresis,  9,  18,  223,  Cases  2,  6,  9, 

12,  15.     Bib.  924,  946,  947,  949,  953, 

9S8. 


INDEX 


Geni to-urinary,  260. 

Genito-urinary  disorder,  see  Urology. 

Geriopsychoses  (senile-senescent  group), 

200,  225,  262. 
Gerver,  31,  Cases  157,  166,  255,  257,  258, 

347,  350,  351,  352. 
Giles,  Case  466,  474. 
Gilles  de  la  Tourette,  18. 
Ginestous,  Case  268. 
Gleboff,  644,  663. 
Glueck,  667. 
Glycosuria,  Bib.  919. 
Goldstein,  723,  728. 
Gonorrhoea,  41,  260,  261. 
Gordon  sign,  157. 
Gosset,  624. 
Gougerot  and  Charpentier,   Cases  428, 

429,  430. 
Gradenigo,  Cases  465,  557. 
Grandclaude,  486. 
Grant,  Dundas,  683,  738,  809. 
Grasset,  405,  501,  522,  523,  638,  724. 
Gray  hair  (see  Canities). 
Green,  Case  169. 
Greenlees,  Case  269. 
Grenier  de  Cardenal,  Legrand,  Benoit, 

Case  118. 
Griinbaum,  Case  532. 
Guillain,  281,  421,  746,  Case  372. 
Guillain  and  Barre,  Cases  31,  112,  382, 

384,  402. 
Gunshot   head    wounds,    see    especially 

under  Encephalopsychoses. 

Hahn,  222. 

Hair  (see  Canities,  H3^ertrichosis) . 
Hallucinations.     Bib.  944,  948. 
Hallucinations,  auditory,  367,  371,  431, 

484,  493;    Bib.  913. 
Hallucinations,  experimental,  460. 
Hallucinations,  Lilliputian,  Case  106. 
Hallucinations,    pain   and    temperature, 

452. 
Hallucinations,  smeU,  478. 
Hallucinations,  tetanus,  164. 
Hallucinations,  visual,  485,  Cases  159. 
Harris,  404,  Case  565. 
Harwood,  Case  436. 
Haury,  Case  46,  154. 
Head,  Hemry,  641. 


Headache,  255,  258,  524,  525,  526. 

Head  injury  (see  also  cases  under  Ence- 
phalopsychoses wounds),  Bib.  905,  906, 
907,  912,  913. 

Head  sensations,  321,  490. 

Heart,  neurosis,  35,  400,  477,  689,  764 
(see  also  Soldiers'  heart,  Precordial  sen- 
sations).   Bib.  909,  914,  927,  929,  930, 

931,  934,  936,  937,  945,  95°,  95i,  959, 

968,  969,  974,  975,  976,  977. 
Heat  stroke,  447. 
Hecht,  838. 

Heilbronner's  sign,  157. 
Heitz,  Case  134. 
HeHo therapy.  Bib.  954. 
Helmet,  Bib.  916. 
Hemeralopia  (see  night-blindness). 
Hematology  (see  Blood). 
Hematomyeha,  277,  284,  286,  555,  570. 
Hemeralopia,  Bib.  907,  914,  927,  929. 
Hemiageusia,  476. 
Hemianosmia,  476. 
Hemianesthesia,  876,  Cases  114,  218,  255, 

376,  380,  554.     Bib.  958. 
Hemianopsia,  428,  616.     Bib.  930,  931, 

953,  974,  977- 

Hemicontracture,  529, 

Hemichorea,  411. 

Hemiplegia,  282,  293,  302,  874,  especially, 
877,  Cases  255,  256,  281,  291,  292,  372, 
408,  412,  551,  554.  Bib.  926,  931,  934, 
936,  943,  945,  946,  949,  953,  958,  959, 
960,  964,  966,  971,  977. 

Hemiplegia,  organic,  minor  signs  of,  157. 
Bib.  925,  933,  950. 

Hemorrhages  of  brain,   265,   270.     Bib. 

955- 
Hemorrhage,  bladder,  Case  202. 
Hemorrhages,  meningeal,  270,  271,  372. 

Bib.  933. 
Hemorrhages,     naso-pharyngeal.       Bib. 

921. 
Hemorrhages  of  skin,  358,  362. 
Hemorrhage,  spinal,  888,  Cases  202 ;   372. 
Henderson,  Case  183. 
Heredity,  289,  401,  418,  419,  668,  812. 
Heredity   and   acquired    soil    absent   in 

SheU-shock,  348,  349,  401,  418,  419. 
Herpes,  288. 
Hesnard,  212. 


lO 


INDEX 


Heterosuggestion  —  frontispiece,  109, 153, 

395.  674,  676,  767,  777,  794,  90i- 
Hewat,  Cases  53,  299,  571. 
Hippus,  87. 
Hirschfeld,  Case  484. 
Histology-,  265,  271,  272. 
Hollande  and  Marchand,  Case  141. 
Homosexuality,  257. 
"Hone>Tnoon"  psychotherapy,  899. 
Hoover's  sign,  157. 

Horse  (in  the  unconscious).  Case  369. 
Hospital  organization,  896.     Bib.  907. 
Hoven,  Cases  156,  183,  333. 
Howland,  748. 
Hunger  dreams,  475. 
Hunter,  John,  608. 
Hurst,  91,  736,  Cases  4,  15,  24,  25,  64,  72, 

78,  80,  238,   378,  399,  501,  514,   527, 

538,  543,  548. 
Hydrophobia,  Case  118. 
Hydrotherapy  (see  Treatment),  Bib.  905, 

906,  911,  929,  936. 
H>-peralbuminosis     (see     Spinal    fluid), 

Cases  371,  373. 
Hyperalgesia,  288,  299,  579,  583.     Bib. 

951- 
Hyperacusis,  367. 
Hyperboulia,  859. 
Hy^peresthesia,  267,  700,  Cases  221,  223, 

262,  383.     Bib.  960. 
Hy-perreflexia,  hysterical,  535. 
Hypersensitive  phase  (see  Anaphylaxis). 
Hj-pertension,  spinal  fluid,  282,  283. 
Hyperthyroidism,  361,  639,  640,  760,  844, 

846,  866,  Cases  142-145,  315,  326,  497. 

Bib.  939,  965. 
Hypertonus  (see  passim),  543,  545. 
Hypertrichosis,  89,  567. 
Hypnotism  in  blind,  377. 
Hj-pnotism,  96,  282,  509,  532,  554,  702, 

729   (blind),   731    (deaf),   743    (not  in 

French  army).   Cases   142,    174,   361, 

369.    Bib.  934,  951,  953,  955,  957,  964, 

967. 
Hj^jnotism,  spontaneous,  504-508. 
Hypochondria,  231,  260. 
Hj-pophrenoses      (Feeble-mindednesses) , 

Cases  35-52,  236.     Bib.  920,  935,  940, 

941,  942,  957,  962,  977. 
Hypotonia,  350,  592. 


Hysteria,  69,  152,  165,  211,  213,  253, 
Cases  67,  68,  123,  128,  137.  Bib.  917, 
924,  930,  932,  940,  942,  943,  944,  945, 
952,  956,  957,  965,  973,  974,  975,  978, 
979,  982. 

Hysterical  s>Tnptoms  in  sleep,  554. 

Hysterical  and  organic  s>TTiptoms,  Cases 
116,  117,  134,  214,  219,  230,  231,  399, 
495.     Bib.  924,  928,  933,  981. 

Hystero-emotive  factors,  456,  509. 

Hystero-organic  association,  605,  799. 

Hystero-reflex  association,  605. 

Hystero- traumatism,  531,  544,  545,  560, 
568,  571,  799.     Bib.  918,  933. 

Imaginary  symptoms,  833. 

Imboden,  288,  693,  793. 

Incontinence    of    u.rine     (see    Urology'), 

Cases  384,  401,  500,  577. 
Indemnity-neurosis,  348. 
Industrial  medicine,  854,  873. 
Infection     (see   also    Somatopsychoses), 

488,  509,  875. 
Inferno,  passim. 

Inhibition,  355,  356,  369,  653,  891. 
Inoculation  and    convulsions   (see  Con- 

\'\ilsions) . 
Insomnia,  299.     Bib.  945. 
Insular  sclerosis  (see  Multiple  Sclerosis). 
Intermediolateral  tract  shock,  526. 
Iron  cross  and  psychopathy,  863,  Case 

158. 
Iron  cross  and  psychotherapy,  Case  479. 
Instinct  (see  Emotion,  Psychology,  etc.). 

Bib.  921,  934,  978. 
Insubordination,  77,  Cases  47,  59,  60,  63, 

93. 
Isolation,  see  Treatment. 

Jacquet's  biokinetic  treatment,  646. 
James,  632,  901. 

Jeanselme  and  Huet,  538,  Case  441. 
Jelly-fish  not  shocked,  858. 
Joint-disease,   539,   545,   562,   569*   608, 

744,  789- 
Jolly,  Cases  176,  349. 
Joltrain,  Case  245. 
Jones,  692,  Case  476. 
Joubert,  Case  374. 
Jousset,  609. 


INDEX 


II 


Jumping-jack,  Case  555. 

Jung,  240. 

Juquelier,  Case  58. 

Juquelier  and  Quellien,  97,  Case  81. 

Kaplan,  700. 

Karplus,  348,  Cases  27,  140. 

Kastan,  860,  Cases  11,  12,  13,  44,  45,  47, 

49,  89,  90,  91,  92,  93,  94,  95,  96,  97, 

104,  148,  151. 
Kaufmann's  Treatment  (see  Treatment, 

Shell-shock  Neuroses,  Psychoelectric) , 

723,  75°,  753,  786,  791,  792,  793,  900- 

Bib.  940,  945,  962,  968. 
Khoroshko,  227. 
Kidner,  803. 
King,  Edgar,  210. 
Klippel  and  Weil,  528. 
Knee-jerks,  loss  of  (matutinal),  Case  110. 
Kocher,  343. 
Korsakow    syndrome,   in  malaria.   Case 

130.     Bib.  916,  930. 
Kyphosis,  340. 

Labilizing  factors,  329. 

Labyrinth  disease,  366,  623,   Case  211. 

Bib.  955,  966. 
La  CaroUe,  660. 
Laehr,  689. 

Laignel-Lavastine,  14,  570,  796,  899. 
Laignel-Lavastine  and  Ballet,  Cases  38, 

438. 
Laignel-Lavastine    and    Courbon,     560, 

Cases  29,  106,  170,  194,  314. 
Laignel-Lavastine  and  Fay,  Case  74. 
Lannois  and  Chavanne,  657. 
Laryngology,  576,  683,  721,  723,  726,  727, 

766,   823    (see  also  Treatment,   SheU- 

shock     neuroses,     pseudo-operations). 

Bib.  909,  912. 
Lasegue,  452,  483. 
Lattes,  257. 
Lattes  and  Goria,  Cases  196,  266,  295, 

319,  321,  322,  323. 
Lautier,  36,  Cases  42,  48,  56. 
Lebar,  569,  Cases  211,  456. 
Lepine,  18,  27,  30,  72,  73,  75,  81,  82,  91, 

112,  113,  120,  126,  155,  202,  231,  260, 

458,  473,  490,  638,  860. 
LerebouUet  and  Mouzon,  Case  105. 


Leri,  498,  696,  723,  Cases  114,  228,  393. 

Leri,  Froment  and  Mahar,  Case  411. 

Leri  and  Roger,  Cases  252,  468. 

Leriche,  886,  Cases  66,  206,  207. 

Levy,  331. 

Lewandowski,  348,  674,  724. 

Lewitus,  Case  471. 

Lhermitte,  157,  874,  887,  Case  103. 

Liebault,  726,  Cases  261,  447,  580,  585. 

"Lightning  neuroses,"  881. 

Lilliputian  hallucinations,  Case  106. 

Lipomatosis,  846,  Case  141. 

Lloyd  Morgan,  374. 

Localizing  sense,  557. 

Localization  of  hysterical  symptoms  (see 

passim)  529,  855,  872,  873. 
Locus    minoris    resistentiae,    Shell-shock 

hysteria,  36,  854,  876,  Cases  286-301, 

409-414. 
Loewy,  Cases  87,  122,  310. 
Logre,  Cases  21,  62,  88,  164,  235. 
Long,  Case  10. 

Lortat- Jacob  and  Sezary,  Case  316. 
Lumbar  puncture  (see  Spinal   fluid  and 

Treatment). 
Lumiere  and  Astier,  Case  119. 
Lumsden,  645. 
Lungs,  846. 
Lust,  228. 

Lymphatics,  Bib.  906. 
Lymphocytosis  of  spinal  fluid  (see  Spinal 

fluid  and  Meningitis). 

MacCurdy,  683,  Cases  193,  232,  293,  307, 

332,  355,  415,  451,  452,  586. 
MacMahon,  738,  Cases  582,  583. 

MacKenzie,  641. 

Main  d' accoucheur,  593. 

Mainfigee,  593. 

Main  succulent,  186. 

Mairet,  401. 

Mairet  and  Durante,  294. 

Mairet  and  Pieron,  92,  Cases  28,  69,  448, 

450. 
Mairet,   Pieron,   Bouzansky,    134,    Case 

330. 
Maitland,  225. 
Maixandeau,  Case  107. 
Malaria,  845,  Cases  129-131.     Bib.  923, 

926,  961. 


12 


INDEX 


Malingering  (see  Simulation,  Medico- 
legal, etc.),  514,  554,  642,  643,  707,  717, 
Cases  453-472.  Bib.  920,  927,  931, 
936,  938,  940,  948,  950>  955,  958,  969, 
974,  975,  976,  982. 

Mallet,  487,  Cases  354,  444,  445. 

Mania,  Cases  163, 165, 187, 188,  350,  351. 

Manic-depressive  psychoses  (Cyclothy- 
moses),  Cases  163-169. 

Manic-depressive  (also  see  Cyclothymia), 
Case  16. 

Maniere  forte,  189,  893,  895,  901. 

Mann,  718,  793,  797,  Cases  240,  265,  356. 

Mannkopf-Thomayer  test,  415. 

Marage,  809,  813. 

Marchand,  Cases  127,  128. 

Marie,  14,  159,  342,  648,  796,  Cases  403, 
470. 

Marie,  Chatelin,  Patrikios,  Case  9. 

Marie-Foix  sign,  157. 

Marie  and  Levy,  Case  213. 

Marie,  Meige,  B6hagne,  Case  401. 

Marionette  movements,  350. 

Marriage,  H.  J.,  Case  260. 

Martial  misfit,  415,  668. 

Martinet,  231. 

Massage,  353,  529,  566.     Bib.  918,  940, 

959,  961,  971- 

Mathieu,  796. 

Maurice,  231. 

Maiivaise  volonte,  717,  812,  894,  Case 
228. 

McDougall,  374. 

McDowell,  Cases  495,  500. 

McWalter,  391. 

"  Mechanisms,"  890,  891. 

Mechanotherapy  (see  also  Treatment), 
Bib.  914. 

Medicolegal,  509  (see  also  Desertion,  Fu- 
gue, Epilepsy,  Simulation,  etc.),  837, 
838,  841,  862,  864,  Cases  1,  3,  11. 
Bib.  914,  917,  920,  925,  926,  932,  935, 
938,  940,  941,  942,  943,  944,  952,  953, 
956,960,961,973,977. 

Medicolegal  period  in  general  paresis,  18. 

Meige,  331,  432,  465,  696,  746,  Cases  224, 
308,  413. 

Meiopragia,  592. 

Melancholia,  Cases  164,  166,  168,  169. 

Memory  (see  Amnesia,  Hypnosis,  etc.). 


Mendel-Bechterew's  sign,  157. 

Mendelssohn,  Cases  111,  208. 

Meniere's  disease,  623. 

Meninges  (see  also  Hemorrhage),  Bib. 
912  (cysts). 

Meningitis,  875,  Case  109.  Bib.  927,  930, 
967.  _ 

Meningitis  (Meningococcus),  Cases  107, 
108.     Bib.  906. 

Meningitis  (pneumococcus) ,  Case  112. 

Mental  disease  (in  war),  926,  936,  937, 
963,  966,  967,  975,  980,  981,  982. 

Mental  hygiene,  Bib.  955. 

Mental  symptoms,  Bib.  917. 

Meriel,  548. 

Merklen,  Cases  125,  126. 

Metatraumatic  hysteria,  329. 

Meyer,  50,  208,  222. 

Meynert,  62,  226. 

Micawber,  674. 

Micromegalopsia,  Case  106. 

Micro-organic  changes,  572. 

Milian,  501,  638,  Cases  171,  364,  365,  366. 

Military  psychiatry  (see  War  and  Psy- 
chiatry). 

Milligan  and  Westmacott,  365. 

Milligan,  775. 

Mills,  Cases  454,  459,  517. 

Mine-explosion,  492. 

"Miracle"  cures  (see  Treatment,  Shell- 
shock,  rapid  versus  slow,  and  passim, 
885). 

Mitchell,  Weir,  821. 

Mobilization,  neuropsychiatry  of,  Bib. 
908,  929. 

Molecular  changes,  572. 

Monier-Vinard,  388. 

Monoplegia,  282,  317,  318,  323,  539,  591 
(diagnostic  table),  595,  596,  605,  874. 
Cases  (crural),  229-234,  286,  287,  385, 
386,  388,  410,  428,  534,  575,  577,  Cases 
(brachial),  249-254,  281,  404,  405,  409, 
421,  426,  427,  429,  430,  563,  564,  571, 
573.     Bib.  954. 

Montembault,  222. 

Moore,  641,  644. 

Morale,  9,  257,  903. 

Morchen,  228. 

Morestin,  Case  516. 

Morphinism,  Cases  99-102. 


INDEX 


13 


Morselli,  222,  226,  645. 

Mott,  158,  228,  476,  643,  689,  704,  719, 
728,  775,  797,  813,  884,  885,  887,  888, 
901,  Cases  85,  197,  262,  328,  341,  344, 
414,  473. 

Muck,  726, 

Multiple  sclerosis,  309,  422,  530,  580,  876, 
Case  115. 

Musculospiral  nerve,  540. 

Musical  alexia,  775. 

Mutism,  282,  454,  Cases  185,  219,  226, 
227,  283,  330,  356,  365,  447,  473,  475, 
476,  480,  516,  520,  526,  528,  531,  544, 
550,  555,  556,  559,  578,  586.  Bib.  916, 
924,  927,  931,  932,  933,  946,  954,  964- 

Mutism,  classification  (Myers),  369. 

Mutism,  treatment,  674  and  passim. 
Bib.  915,  927,  976. 

Myelitis  (see  Spinal  cord  lesions). 

Myers,  355,  568,  579,  740,  750,  Cases 
174,  223,  263,  272,  287,  329,  360,  361, 
395,  453,  463,  464,  523,  524,  525,  538. 

Myokymia,  361. 

Myopathy,  question  of  Shell-shock,  574. 

Narcolepsy,  487,  843,  Case  77. 

Narcosis  (see  Treatment,  Narcosis). 

Naval  Service,  Bib.  910,  929,  965. 

Neiding,  Case  215. 

Neisser,  838. 

Neri's  sign,  452. 

Nerve  concussion,  354. 

Nerve  leaks.  Bib.  910. 

Nerve  lesions,  peripheral  (see  also  Neuri- 
tis), Bib.  905,  909,  910,  916,  918,  920, 
921,  925,  926,  928,  933,  934,  935,  936, 

937,  938,  939,  941,  945,  947,  948,  949, 
950,  951,  953,  955,  956,  957,  958,  959, 
960,  963,  965,  967,  968,  970,  971,  972, 
973,  975,  976,  977  (large  nerve  trunks), 
923  (median),  914,  923  (electrical 
methods  of  diagnosis),  922. 

Nerve  sutures,  916,  926. 

Nerves  (and  the  War),  915,  953,  956. 

Nervous  system,  922,  923,  925,  928,  933, 

938,  940,  944,  945,  958,  959,  962,  963, 

967,  971,  972,  973,  975,  978. 
Nervous  temperament,  956. 
Neurasthenia,  231,  578,  639,  718,  Cases 

143,  175,  176,  177,  179,  284,  340,  349, 


416,  420,  545.    BI6.  914,  915,  916,  920, 

925,  930,  950,  957,  964,  969,  975,  980. 
Neuritis,   89,   574,   583,   598,   843,   846, 

Cases  127,  128,  130,  131,  132,  135,  387, 

417,  418,  512,  540.   Bib.  907. 
Neuropsychiatry,  Bib.  915, 922,  924,  926, 

947,  951,  952,  955,  960,  963,  969,  976, 

980. 
Neurological  centers.  Bib.  918,  923,  941, 

956,  961,  966,  971,  972,  981. 
Neurologists  in  war.  Bib.  914. 
Neurology  (see  War  and  neurology). 
Neuropotential,  268. 
Neurosis,  definition,  831-834,  889.     Bib. 

926,  938,  939,  946,  947,  952,  957. 
Neurosyphilis,  Cases  1-34,  53, 110.    Bib. 

916,  972. 
Neurosyphilis  and  exhaustion,  31. 
Neurosyphilis  and  trauma,  838. 
Night-blindness,  Bib.  907,  911,  942,  959, 

975,  979,  980. 
Nitrophenol,  Case  434. 
Nitrous  oxide  anesthesia,  769. 
Noise,  308. 
Nonne,    282,   348,    716,    718,    736,    748, 

Cases  248,  479,  530,  531,  533,  535,  536. 
Nose,  see  Rhinology. 
Nosophobia,  Case  261. 
Nostalgia,  440.     Bib.  927. 
Nystagmus,   432,   489,   557.     Bib.   952, 

956,  975- 

Obsessions,  229,  466,  631. 

Obturators,  aural,  813. 

Obtusion,  487,  especially,  637. 

Occipital  lesions,  159,  217. 

Ofiicers'  susceptibility  to  Shell-shock, 
735,  744,  857. 

Old  age,  200,  225,  262. 

O'Malley,  Cases  515,  518. 

Oniric  delirium,  405,  437,  456,  477,  478, 
628,  Cases  50,  81,  295,  314,  319,  321, 
331,  333,  444,  477,  579. 

Oniric  delirium,  treatment  by  prear- 
ranged emotional  shock,  461. 

Ontological  fallacy,  833. 

Ophthalmology  (see  Vision,  etc.),  Cases 
268-272,  433-438.  BiB.  906,  907,  910, 
911,  916,  918,  930,  931,  938,  941,  944, 
954,  955,  970- 


14 


INDEX 


Ophthalmoplegia,  Case  19. 
Ophthalmoplegia  externa,  613. 
Oppenheim,  157,  348,  361,  401,  747,  749, 
Cases  146,  256,  311,  326,  376,  379,  405, 

420,  427. 

Organic  neurology  (see  Encephalopsy- 
choses,  Trauma,  and  passim),  158- 
161,  489.    Bib.  914. 

Organo-hysterical  association,  605.  Bib. 
916. 

Organopathic,  856,  871. 

Orientation-sense  (see  Otology). 

Ormond,  653,  Case  537. 

Ormond  and  Hurst,  729. 

Orthopedics,  356,  692.    Bib.  906,  910,  915, 

927,  931,  939,  947,  950,  953,  957,  963, 
970. 

Otology  (see  Ear,  Labyrinth,  Vestibular, 
Deafness,  Mutism,  Aviation),  888, 
Cases,  259-267,  370,  414,  439,  440, 
497-499,  562,  578,  579,  588.  Bib.  907, 
913,  916  (Equilibrium,  Orientation), 
919,  925,  962. 

Over-reaction,  307. 

Over  the  top,  481,  699. 

O\'erwork,  11. 

Pachantoni,  Case  273. 

Pactet  and  Bonhomme,  Case  52. 

Pain,  see  Antalgic  hallucinations. 

Panic  (see  Psychology,  Emotion,  etc.). 
Bib.  922. 

Paranoia,  Case  185.     Bib.  960. 

Paraphernalia,  785  (see  Atmosphere  of 
cure) . 

Paralyses  (see  also  Hemiplegia,  Mono- 
plegia, Paraplegia,  etc.),  (P.  Bra- 
chialis),  Bib.  919,  943;  (traumatic), 
923,  927,  933;  (facial),  955;  (func- 
tional), 977. 

Paraplegia,  282,  284,  541,  769,  Cases  236- 
241,  279,  288,  374,  379,  387,  393,  394, 

421,  479,  511,  536,  555,  568,  572.  BiB. 
919,  923,  926,  927,  929,  930,  935,  938, 
939,  947,  949,  95°,  952,  956,  966. 

Paratyphoid  fever,  psychosis,  845,  Cases 

125,  126.     Bib.  952. 
Paresthesia,  357,  359. 
Parinaud,  618. 
Paris,  84. 


Parkinson,    Cases  138,  139.     Bib.    933, 

958. 
Parkinson's  disease,  422. 
Parsons,  653,  Case  270. 
Pastine,  693. 
Pathological  into.xication.  Cases  86,  87, 

90,  96. 
Pathological  lying.  Case  183. 
Paulian,  576,  Case  385. 
Pearson,  373. 

Pellacani,  Case  59,  60,  187. 
Pemberton,  Case  271. 
Penhallow,  769. 
"Pensionitis,"  666. 
Pensions  (see  Medicolegal),  Bib.  914. 
Periorganic     hysterical    symptoms    (see 

passim),  529-534,   544,   548   (tetanic), 

563,  569,  849,  873. 
Personality  disorder  (see  also  passim  and 

Psychopathoses) ,  493,  512.     Bib.  927. 
Persuasion,  96.     Bib.  927. 
Petrol-injection,  Case  98. 
Pharmacopsychoses  (Alcohol,  Drug,  and 

Poison  group).  Cases  86-102.  Bib.  925. 
Phillipson,  364. 
Phobia    (see    Psychoneuroses,    Psychas- 

thenia),  627,  628. 
Phobias,  464. 

Phocas  and  Gutmann,  846,  Case  136. 
Photophobia,  372,  511. 
Physiopathic  declacification,  Case  429. 
Physiopathic  disorder,  380,  521,  543,  544, 

554,  585  (diagnostic  table),  Cases  274- 

281,   421-428;    591  (diagnostic  table), 

878,  892.     Bib.  932,  953,  954,  956,  964, 

966,  977,  978. 
Physiopathic  electrodiagnostics,  608. 
Physiopathic  disorder,  cure,  387,  607,  671. 

Bib.  928. 
Physiotherapy,  821,  896,  897.     Bib.  914, 

918,  920,  926,  929,  931,  935,  939,  948, 

950,  951,  957,  960,  967,  975,  978. 
Pick,  Case  33. 
Piedfige,  330. 
Pitres  and  Marchand,  837,  Cases  23, 109, 

115,  218. 
Pitres  and  Regis,  423. 
Pituitrin,  228,  690. 
Plantar  reflex,  question  of  absence,  537, 

538,  575.     Bib.  923. 


ESTDEX 


Pleocytosis  (see  Spinal  fluid). 

Pleura,  hemorrhage,  Case  201. 

Pleura,  reflex  disorder,  186,  846. 

Plicature  (see  Camptocormia). 

Plumbism,  584. 

Pneumonia,  Case  133. 

Podiapolsky,  740,  Cases  539,  540. 

Podnmnizky,  693. 

Poliencephalitis,  26. 

Poliomyelitis,  574,  598. 

Pol}Tieuritis  neurasthenica  (Mann),  718. 
Bib.  925,  957. 

Poliomyelitis,  residuals.  Case  113. 

Pollakisuria,  347 

"Poor  dears!",  719. 

Popliteal  nen.^e,  354,  540,  600. 

Post-diphtheritic  symptoms.  Case  127. 

Post  mortem  (see  Autopsies). 

Post-oniric  suggestion,  477,  628. 

Potain,  239. 

Pott's  disease,  343. 

Precordial  sensations,  477,  526. 

Predisposition,  401  (see  also  frontispiece). 

Prefrontal  lesions,  159. 

Pregnancy,  hysterical,  387,  Case  348. 
Bib.  966. 

Prestige,  819. 

Prevention  of  Shell-shock,  3,  902. 

Prince,  Morton,  902. 

Prisoners,  228,  303.     Bib.  913. 

Proctor,  769,  Cases  480,  556. 

Pruvost,  Cases  35,  36,  37,  39,  41. 

Pseudodementia,  Bib.  910. 

Pseudologia  phantastica.  Case  183. 

Pseudocoxalgia,  323,  341,  819. 

Pseudohallucinations,  430. 

Pseudo  multiple  sclerosis,  155. 

Pseudoparesis,  Case  26. 

Pseudoptosis  of  Charcot  and  Parinaud, 
618. 

Pseudotabes,  Case  23. 

Psoitis,  525. 

Psoriasis,  Case  313.     Bib.  930. 

Psychasthenia,  Cases  170,  178,  194,  342, 
347.    Bib.  910,  921,  929,  942,  975,  980. 

Psychiatric  social  work.  Bib.  917,  938, 
956,  972. 

Psychiatrists  in  war.  Bib.  914,  927,  950. 

Psychiatry  in  war  (see  War  and  psy- 
chiatry). 


Psychoanalysis,  361,  497,  582,  675,  677, 
702,  712-716  (rationalization),  851,  901 
(autognosis) .     Bib.  926,  937,  979. 

Psychoelectric  treatment,  285,  313. 

Psychogenesis,  69,  83,  332,  337,  348,  351, 
497,  744,  S55,  871.     Bib.  919. 

Psychological  laboratory,  896. 

Psychology,  passim,  also  Bib.  907,  911, 

924,  925,  928,  931,  932,  934,  936,  937, 

938,  941,  943,  946,  947,  952,  955,  956, 

959,  960,  962,  963,  964,  968,  971,  873, 

876,  982. 
Psychoneuroses,     Cases    170-182.     Bib. 

926. 
Psychoneuroses  of  war,  Charts  11  and  12, 

pages  522  and  523,  760,  761,  799.     Bib. 

932,  940,  941,  943,  955,  956,  959,  960, 

961,  965,  966,  972,  973,  976,  978,  981. 
Psychopathic  constitution.  Case  147. 
Psychopathic  hospitals,  3,  680,  871. 
Psychopathic  inferiority.  Case  186. 
Psychopatholog}^  of  War,  Bib.  917,  922, 

926,  954,  971,  972. 
Psychopathoses    (Psychopathias) ,    Cases 

183-196.     Bib.  935,  948,  957,  960,  962, 

969,  977,  980- 

Psychoses,  2-262,  Chart  i  (page  2).  Bib. 
915,  918,  922  (acute),  926  (post-shell- 
shock),  927  (Dysglandular) ,  927,  928, 
934,  936,  940,  (vesical)  943,  952, 
955,  957,  958,  962,  965,  968,  972,  973, 
975,  976,  978,  979,  980,  982  (see  also 
Mental  diseases  [in  war]). 

Psychoses,  treatment,  Bib.  918. 

Psychotherapy  (see  Treatment);  also 
chart  16  (page  673). 

Psychotic  symptoms  in  hysterical  cases, 

327- 
PueriUsm,  Case  318.    Bib.  912,  917,  941. 
Pulmonary  phenomena,  846. 
Pupils  in  Shell-shock,  526.     Bib.  933. 
Purser,  Case  475. 

Quadriplegia,  528,  530,  551,  573. 
Quincke's  disease,  646,  665. 

Rabies,  844,  Case  118. 
Radial  paralysis,  350,  351. 
Radicular  symptoms.  Case  134. 
Railway  spine,  5,  348,  544,  831,  873. 


i6 


INDEX 


Raimiste,  528. 

Ranjard,  809. 

Rationalization  (Rivers),  Cases  506-510 
(see  also  Treatment:  Shell-shock  neu- 
roses), 237,  859. 

Ravaut,  275,  281,  Cases  202,  373,  408, 
488. 

RajTiaud,  569. 

Reaction-psychosis,  304. 

Reactive  idealization,  468. 

Realsuggestionen,  799,  803. 

Reconstruction,  831,  859,  893  (see  Treat- 
ment, Shell-shock  neuroses.  Mechano- 
therapy, Reeducation,  etc.,  etc.,  and 
passim).    Bib.  908. 

Recovery  (see  SheU-shock). 

Recruits,  possible  elimination  of  defective 
(see  also  Hypophrenoses),  835,  858. 
Cases  42,  44,  49,  91.    Bib.  906. 

Rectal  incontinence,  807. 

Recurrence,  Cases  286-301. 

Reeducation  (see  Treatment,  Shell-shock 
neuroses.  Reeducation),  also  Bib.  906, 
914,  915,  916,  918,  920,  922,  923,  925, 
926,  927,  928,  930,  931,  933,  935,  937, 
938,  940,  942,  943,  948,  949.  950,  951, 
952,  954,  956,  957,  961,  962,  963,  964, 

969,  971,  978. 

Reeducation,  respiratory,  808,  814-818. 
Reeve,  793,  Cases  489,  490,  491,  492,  493. 
"Reflex"  disorder  (see  Physiopathic) . 
Reflexes,  Bib.    919,  925,  934,  939,  953, 

970,  971,  977,  978. 
Refrigeration,  424,  590. 

R6gis,  62,  72,  233,  461,  478,  509,  631,  637, 
638,  680,  850. 

Relapse  (see  also  "Reminiscence"  proc- 
ess in  shell-shock),  403,  404,  457,  463, 
495,  675. 

Religiosity,  256. 

"Reminiscence"  process  in  Shell-shock 
hysteria,  Cases  286-301,  314. 

Responsibilit}^  (see  Desertion,  Fugue,  In- 
subordination, Pharmacopsychoses)  ,72, 
100,  117,  171. 

Responsibility  a  psychogenic  factor,  458. 

Retention  of  urine  (see  also  Urology), 
Cases  111,  382,  383,  539  (Hypnotism). 

Retrobulbar  neuritis,  609,  Case  434. 

Retrocentral  lesions,  160. 


Rhinolog}',  262,  321,  375,  476,  511,  665. 

Bib.  955. 
Riggall,  Case  541. 
Rivers,  476,  Cases  506-510. 
Rombergism,  Shell-shock,  620. 
Romner,  Case  406. 
Rontgenology  (see  X-Ray). 
Rosanoff-Saloff,  ISIme.,  340. 
Roselle  and  Oberthur,  456. 
Rossolimo's  sign,  157. 
Rothacker,  Case  144. 
Rouge,  Cases  153,  162. 
Roussy,   281,  696,  Cases  133,  279,  387, 

460,  497,  498,  499,  502. 
Roussy  and  Boisseau,  275,  362,  404,  689, 

743,  797,  8x5,  887,  Cases  199,  440. 
Roussy,  Boisseau,  Comil,  Case  348. 
Roussy   and  Lhermitte,   466,   471,   476, 

487,  509,  525,  560,  563,  578,  637,  701, 

726,  738,  743,  787,  807,  896,  Cases  230, 

235,  243,  244,  246,  247,  250,  291,  572, 

584. 
Routier,  Case  409. 
Rows,  471,  478,  900,  Cases  301,  335,  342, 

343. 
Russca,  295. 
Russel,  404,  650,  740,  775,  781,  Cases  79, 

241,  503,  504. 

Saaler,  208. 

Salmon,  804. 

Sargent  and  Holmes,  158. 

Sartorius  muscle,  553. 

Savage,  48,  83,  404. 

Schafer's  sign,  151. 

Schizophrenia  and  tj^ihoid  fever.  Case 
124. 

Schizophrenoses  (Dementia  prascox 
group),  202,  223,  861-865,  864  (medi- 
colegal),   Cases    124,    147-162.     BiB. 

913- 
Scholz,  Case  550. 
Schultz,  726. 
Schultzer,  Case  570. 
Schuster,  343,  349,  Cases  19,  234,  298. 
Sciatica,  Cases  10,  565. 
Scotoma,  98,  374. 
Sebileau,  Case  388. 
Secretory  disorder,  387. 
S6guin  and  Rouma,  809. 


INDEX 


17 


Self-inflicted  injury,  Cases  153,  187,  193. 

Bib.  917,  921,  922,  926,  961,  969. 
Sencert,  885,  Case  201. 
Semlity  (see    Geriopsychoses),  200,  225, 

262. 
Sensibility    (see    Dermatology,    Opthal- 

molog>',  etc.).    Bib.  923,  946,  955,  962, 

969,  978,  980. 
Serbians,  102,  225,  228. 
Sereysky,  297. 
Serology     (see     Syphilopsychoses,     also 

under  Spinal  fluid). 
Sexual  continence,  459. 
Sex  sensations,  259. 
Shell-shock:  minimal  experimentation,  294, 

295- 
"Shell-shock,"  the  term,  5. 
Shell-shock  and  croix  de  guerre,  430,  675. 
Shell-shock:     Diagnosis,  Cases   371-472 

a.nd  passim.    Bib.  915,  922,  941. 
Shell-shock:    Nature  and  Causes,  Cases 

197-370  and  passim.     Bib.  917,  918, 

920,  926,  927,  928,  935,  937,  942,  958, 

967,  977,  9^1. 
Shell-shock:     Treatment     and     results, 

Cases  473-589  (and  see  special  head- 
ings   under    Treatment,    Shell-shock). 

Bib.  967. 
"Shell-shock"  diseases,  880. 
Shell-shock     and     epilepsy      (Ballard's 

Theor>0,  Cases  82-84. 
Shell-shock  and  traumatic  neurosis.  Case 

248. 
SheU-shock  equivalent,  850. 
Shell-shock,  general  arrangement  of  cases, 

852  et  seq.,  879-880,  883,  894  et  seq. 
Shell-shock,  nature  in  general,  847,  867, 

880-892.     Bib.  926,  931,  932,  934,  946, 

95o>  952,  953,  954,  955,  961,  962,  965, 

967,  968,  971,  974. 
Shell-shock:     organic    hypotheses,    526, 

Cases  197-222.     Bib.  927. 
SheU-shock,  relapse,  391. 
Shell-shock,  repeated,  299. 
Shell-shock   (spelled  with  capital  letter) 

versus  sheU-shock  (spelled  lower  case), 

880. 
Shell-shock,    sjTnptoms    delayed.    Cases 

282-285. 
SheU-shock,  terminology,  831-834. 


SheU-shock,   treatment  in  general,   893, 
adfinem.     Bib.  921, 923,  924,  929,  930, 
934,  936,  937,  953,  954,  976,  978. 
"Shock"  ought  to  be  "functional,"  883. 
Shufflebotham,  Case  417. 
Shunhoff,  228. 

Shuttleworth,  48. 

Sicard,  525,  S44,  554,  643,  Case  462. 
Simulateurs  de  creation,  de  fixation,  643. 

Simulation  (see  maUngering,  medicolegal, 
etc.),  42,  91,  260,  569,  592,  605,  es- 
peciaUy  642-667;  661-662  (Ust  of 
methods).  Bib.  914,  916,  917,  922, 
925,  927,  928,  932,  934,  936,  939,  940, 
941,  942,  945,  946,  949,  953,  955,  95^, 
958,  959,  960,  962,  963,  964,  965,  967, 
969,  970,  974,  975,  976,  977,  978. 

Simulation,  Cases  33,  34,  39,  78,  79,  257. 
Bib.  907,  909,  910,  912,  917,  918,  920, 
924,  946. 

Sirene  a  voyelles,  go8. 

Situation-delirium,  699. 

Skin-lesions  (see  Dermatology). 

Skin  reflexes,  538,  543. 

SkuU,  see  Head  and  Wounds.  Bib.  916 
(Protection,  etc.). 

Slang,  832. 

Sleep,  deep,  70. 

Sleep,  SheU-shock  not  produced  in,  349. 

Sleep,  hysterical  symptoms  persistent  in, 
553.     Bib.  971. 

Smell  (see  Rhinology). 

Smimow,  740. 

Smith,  E.,  471,  Cases  175,  284. 

Smith,  E.,  and  Pear,  T.  H.,  672,  740, 
901. 

Smith,  R.  P.,  Case  192. 

Smyly,  Cases  116,  117,  219,  283,  397, 
520,  558,  559. 

Snake  kiUed,  678. 

Social  work  (see  also  Social  Psychiatry), 
2,  859,  893. 

Soldier,  Bib.  927;  Mind  of,  in  field.  Bib. 
927. 

Soldiers'  heart,  44,  Cases  138,  139,  451, 
452.    Bib.     905,  924. 

SoUier,  538,  554,  603,  Cases  389,  390, 
487. 

SoUier  and  Chartier,  531. 

SoUier  and  Jousset,  Case  434. 


is 


INDEX 


Somatopsychoses      ( ' '  symptomatic ' '     of 

bodily    [non-nervous]    disorder),  843- 

847,  Cases  118-146. 
Somatopsychoses     (Symptomatic,     non- 
nervous  group),  Cases  122-146. 
Somnambulism,   70,  499,  502,  503,  504, 

506,  508,  509. 
Soukhanoff,  120,  Cases  50,  223. 
Souques,  91,  342,  345,  696,  886,  Cases 

242,  386. 
Souques  and  Donnet,  Case  371. 
Souques  and  Megevand,  Case  401. 
Souques,  Megevand,  Donnet,  Case  205. 
"  Spa"  treatment,  718.     Bib.  957. 
Spasms,    409,   548,   563,   S7I,   577,  588. 

Bib.  951. 
Spasm,  facial.  Cases  222,  309.    Bib.  944. 
Spasm,  glossolabia],  563,  Case  309. 
Spasm,  head.  Cases  223,  413,  588. 
Spasticity,  427. 
Speech  disorder,  Cases  217,  219,  369,  377, 

527  (see  also  Stuttering).      Bib.  922, 

932,  934,  940,  945,  947,  949,  950,  951, 

955,  968,  969,  975,  979,  981. 
Specialists  in  escape,  81. 
Sphincter-disorder     (see    also  Urology). 

Bib.  916,  933. 
Spinal  cord  lesions,  562,  887,  Cases  111, 

133,    372;    especially    Cases  375-381. 

Bib.  915,  919,  920,  945,  946,  950,  965, 

978. 
Spinal    fluid,    149;     especially    276-283; 

344,  398,  421,  506,  521;  especially  524- 

527;  530.  535,  536,  539,  570,  576,  Bib. 

909,  951,  972. 
Spine  (see  under  Camptocormia). 
Spondylitis,  342,  525,  Bib.  921. 
Spondylotherapy,  Bib.  909. 
Spontaneous  cures  in  SheU-shock,  Cases 

283,  310,  357,  365. 
Spirometer,  366. 
Staircase  test,  190,  533,  640. 
Stansfield,  220. 
Statistics,  222,  227,  228,  362,  753,  784, 

812,  820,  831,  836,  839,  858,  864. 
Steiner,   704,   763,   Cases  181,   182,  312, 

437. 
Stereotyped  movements,  430. 
"  Sterno"  sign  of  Dupuoy,  Case  161. 
Sterz,  Case  123. 


Stewart,  741,  771. 

Stier,  222. 

Stomach,  400,  476,  479,  533,  701,  705, 
716,  807.     Bib.  950,  951. 

Stokes,  268. 

Stovaine  anesthesia,  778,  779. 

Stransky,  866. 

Stress,  226,  227,  867  (see  also  Exhaus- 
tion, Fatigue  and  passim). 

"Stupefaction"  of  muscle,  335,  542, 
890. 

Stupor,  362,  369,  435,  462,  486,  503. 
Bib.  933. 

Stupor,  "local"  (peripheral),  542. 

Stuttering,  681,  638,  817,  Cases  219,  527, 
579,  586  (see  also  Speech  disorder). 

Subconscious,  Bib.  909. 

Suggestion  (see  also  Atito-Heterosugges- 
tion),  frontispiece,  95,  318,  338,  476, 
477,  438,  498,  653,  872.  Bib.  910,  912, 
915,  931,  961. 

Suicide,  257,  258,  261,  283,  351,  460,  468, 
478. 

"Superposition"  of  hysterical  s>Tnptoms, 
531,  533,  545,  Case  68. 

Supinator  longus,  353,  355-892. 

Surgery,  118,  158-161,  Cases  66,  69,  146, 
252  (see  also  Treatment,  Shell-shock 
neuroses,  pseudo-operations).  Bib. 
954,  960,  962,  964. 

Sursimulalion,  656. 

Sympathetic  nerve  effret,  394. 

Sympathy,  718,  719,  901  (see  also  "Poor 
dears!"). 

Sympathy  with  enemy,  245,  258,  319,851. 

S>Tnptomatic  psychoses  (see  Somato- 
psychoses). 

Syncope,  pleural,  187. 

Syndesmitis,  525. 

Synesthesialgia,  433. 

Syphilopsychoses,  836-839,  875,  Cases  1- 
34.     Bib.  934,  937,  941. 

Syphilis  and  epUepsy,  66,  67,  Cases  45, 
55. 

Syphilis,  in  the  army.     Bib.  972,  974. 

Syphilis,  danger  of  vaccination  in,  85. 

Syphilis,  in  married  women,  16. 

Syphilis,  in  munition-workers,  16,  838. 

Syphilophobia,  260. 

SjTingomj'elia,  570,  663. 


INDEX 


19 


Tabes  dorsalis,  Cases  4,  20,  21,  22,  23. 

Bib.  930. 
Tachycardia,  76,  103,  198,  260,  309,  359, 
526,  529,  533,  641,  689.     Bib.  907,  923. 
Tachypnoea,  526,  846,  Case  137. 
Teeth,  701. 

Tension,  arterial  (see  Blood  pressure). 
Tetanos  fruste,  Case  120. 
Temperature  changes  in  hysteria,  331. 
Tetanus,  845,  874,   Cases  99,  119,  120, 

121,  280,  392,  403,  409,  419.     Bib.  913, 

917,  919,  921,  927,  936,  946,  949,  952, 

954,  964,  966,  973- 
Thalamus,  optic,  653,  876,  Case  114. 
Theopaths,  851,  Case  106. 
Thennanesthesia,  Case  380. 
Thermotherapy,  607. 
Thibierge,  16,  30,  83S. 
Thirst  dreams,  475. 
Thorax,  94. 

Thyroid  disease.  Case  186.     Bib.  912. 
Thyroid  extract,  228. 
Tic,  282,  401,  428,  432,  446,  559,  577,  627, 

742.     Bib.  917  951. 
Tinel,  356,  890,  Cases  253,  315. 
Tobacco,  639. 
Todd,  804,  Case  7. 
Tombleson,   846,    Cases   142,    545,    546, 

547. 
Torpillage   (sec    Treatment,   SheU-shock 

neuroses,    psychoelectric),     786,    893. 

Bib.  930,  964. 
Torpor,  487. 

Torticollis,  697.     Bib.  951. 
Toxic  psychosis  (see  Somatopsychoses), 

Bib.  914. 
Trauma  and  general  paresis,   Cases  15, 

18,  20. 
Trauma    and    neurosyphilis    (also     see 

Trauma  and  general  paresis),  Cases  5, 

16,  17,  19,  20,  24,  25,  27. 
Trauma,  spinal,  Cases  375-381. 
Traumatic  neurosis,  347,  359,  749.     Bib. 

915,  929,  930,  931.  935,  937,  946,  948, 

949,  952,  954,  956,  957,  9S8,  962,  967, 

970,  971,  972,  976,  977,  981,  982. 
Traumatic  psychoses  (see  also  Encephalo- 

psychoses),  490,  534,  872,  873.     Bib. 

940,  968. 
Traumatropism,  see  Localization. 


Treatment,  ph5^iopathic  or  reflex  dis- 
order, 671,  743,  787,892,  Cases277-279. 

Treatment,  psychoses,  Bib.  918. 

Treatment,  shell-shock  neuroses;  drugs, 
675,  677,  689,  777. 

Treatment,  SheU-shock  neuroses,  Hydro- 
therapy, 588,  680,  Case  484.  Bib. 
962,  963,  973,  978. 

Treatment,  SheU-shock  neuroses,  H>-pno- 
tism,  347,  367,  499,  515,  532,  676,  681 
(in  writing),  682,  697,  5x4,  especially 
Cases  521-548.     Bib.  970,  975. 

Treatment:  SheU-shock  neuroses  by  in- 
duced fatigue,  789,  Cases  489-493. 

Treatment,  SheU-shock  neuroses,  Isola- 
tion, 575,  672,  695,  708,  812,  820,  901. 
Bib.  929,  930,  937,  942,  966,  967,  969. 

Treatment,  SheU-shock  neuroses,  Limibar 
puncture,  693,  778,  779. 

Treatment,  SheU-shock  neuroses,  Mech- 
anotherapy, 318,  560,  566,  691,  692, 
697,  698,  717,  718,  788,  821,  827.  Bib. 
913,  940,  941,  960,  961,  964,  967,  971. 

Treatment,  SheU-shock  neuroses:  rapid 
versus  slow  methods,  683,  695,  749, 
751,  782-797  (rapid  or  miracle  cures), 
791,  872,  895.     Bib.  965. 

Treatment,  SheU-shock  neuroses,  Nar- 
cosis, 318,  332,  532,  676,  682  (alcohol), 
683  (alcohol),  737,  768  (alcohol),  es- 
pecially Cases  552-559,  but  passim; 
560,  561  (siovaitie). 

Treatment,  SheU-shock  neuroses.  Occu- 
pation therapy,  see  passim,  683,  685, 
711,  803,  859,  893.     Bib.  938,  979. 

Treatment,  SheU-shock  neuroses,  Pseu- 
dooperations,  344,  264,  267,  588,  609, 
646,  821  especiaUy  Cases  514-521;  560 
and  561  (stovaine);   562  (X-ray). 

Treatment,  SheU-shock  neuroses,  Psycho- 
electric,  696,  815,  827,  especiaUy  897 
and  898,  Cases  230,  235,  250,  264,  401, 
404,  418  (628),  478,  513,  514,  555,  559, 
especially  563-574,  584.  Bib.  929, 
930,  932,  942,  943,  948,  967,  976. 

Treatment,  SheU-shock  neuroses:  faith, 
rationalization,  explanation,  persuasion, 
"tracing  back",  reassurance,  etc.,  463, 
474,  580,  622,  69s,  701,  706,  707,  820, 
900,  901.     Bffi.  937,  967,  969. 


20 


INDEX 


Treatment,  Shell-shock  neuroses,  Reedu- 
cation, 568,  683,  692,  735,  899,  900, 
901,  Cases  230,  284,  293,  299,  387,  400, 
404,  447,  514,  550,  especially  576-589, 

578  (respiratory).     BiB.  913. 

Treatment,  Shell-shock  neuroses,  Re- 
covery without  medical  treatment, 
Cases  283,  310,  357,  364,  365,  espe- 
cially 473-477,  520. 

Treatment,  Shell-shock  neuroses,  pre- 
arranged emotional  shock  (see  Emo- 
tion), 680. 

Treatment,  Shell-shock  neuroses,  relation 
to  the  front  line,  675,  897. 

Treatment,  SheU-shock  neuroses,  studied 
neglect,  672,  Cases  67,  533. 

Treatment,  Shell-shock  neuroses,  Psjxho- 
therapy  undefined,  553,  554,  874,  899 
(honejTnoon  type).  Bib.  923,  926, 
950,  966. 

Tremophobia,  465,  Case  308. 

Tremor,  282,  466,  492,  551,  622,  742, 
Cases  224,  308,  325,  327,  337,  483, 
502,    532,   535.     BiB.    909,    945,   950, 

951- 
Tremors,  head,  292,  708. 
Trench-foot,  718,  760,  Case  132. 
Trephining  (see  also  Organic  neurologj-j, 

490. 
Triad  of  Dieulafoy,  373,  609. 
Triplegia,  773. 
Trismus,  300,  771. 
Trophic  changes,  603. 
Tubby,  354,  Cases  254,  285. 
Tuberculosis,  239. 
Turner,  718,  804,  901. 
Turrell,  Cases  121,  568. 
TjTnpanum,  300. 
Tj-phoid  fever,  Cases  123,  124,  135,  276. 

Bib.  229. 
T>-phus  (and  war  psychoses).     Bib.  928, 

955,  960,  970,  972- 

Ulnar  sjTidrome,  Case  136. 
Urology,  Urine,  347,  377,  427,  476,  527, 
533,  especially  535-6,  805. 

Vago-accessorius  nucleus,  265,  884. 
Vagus,  701. 


Vasomotors,  labile,   260,  387,  428,  569, 

639,  742  (also  passim).     Bib.  921  (arte- 
rial hypertension). 
Veale,  Cases  511,  512. 
Venereal  diseases  (see  Syphilis,  Urology, 

etc.).    Bib.  920. 
Verger,  Case  61. 
Vertigo,  Case  105. 
Vestibular  symptoms.  Cases  31,  368,  398, 

439,  515. 
Vicissitudes     of     treatment,     796     and 

passim. 
Victoria  cross,  741,  891. 
Vigourou.x,  44. 
Vignolo-Xutati,  429. 
Vincent,  266,  696,  723,  753,  820,  894,  900, 

Cases  277,  278,  566,  564. 
Vincent's     treatment'    (see     Treatment, 

SheU-shock  neuroses,  psychoelectric). 
Violence,  75,  76,  252-255. 
Vision    (see   also   Ophthalmology),   490. 

Bib.  931,  934,  974. 
Visual  fields,  contracted,  253,  254,  374, 

551.  Bib.  936. 
Vlasto,  Case  519. 
Vocational  reeducation,  803.     Bib.   915, 

916,  917,  924,  926,  930,  940,  971,  973, 

974,  975,  978. 
Voltaic  vertigo,  621,  624. 
Vomiting  (see  Stomach). 
Von  Sarbo,  348,  Case  410. 
Voss,  Cases  455,  457,  569. 
Vulpian,  608. 

Wagner  v.  Jauregg,  348. 

Walshe,  828. 

Walther,  Case  404. 

War  and  Neurology,  Bib.  915,  922,  928, 

934,  938,  946,  950,  951,  952,  953,  954, 
956,  957,  967,  968,  971,  973,  974,  977, 
981. 

War  Neurosis  (see  Shell-shock,  Hysteria, 
etc.). 

War  and  Psychiatry  (see  also  Recruits, 
Hospital  Organization),  Bib.  920,  921, 
922,  925,  926,  928,  930,  931,  932,  933, 

935,  938,  940,  943,  944,  946,  953,  954, 
956,  960,  962,  963,  965,  969,  971,  973, 
974,  977,  979,  980,  981- 

War  stress,  226,  227,  289. 


INDEX 


21 


Wassermann  reaction  in  suspected  Shell- 
shock,  12.     Bib.  927. 

Wassermann  reaction  in  epileptiform 
seizures,  65. 

Weichardt,  689. 

Wernicke,  161,  409. 

Westphal,  348,  Case  435. 

Westphal  and  Hiibner,  Cases  73,  290. 

Weygandt,  863,  Cases  3,  160,  165,  416. 

White  hair  (see  canities). 

Will  therapy,  322. 

Wilmanns,  228. 

Wilson,  Gordon,  812. 

Wiltshire,  404,  519,  675,  Cases  216,  324, 
325,  337,  338,  345,  357. 

Windage,  185,  275,  276,  289,  317,  378, 

550- 

Wish-fulfillment,  361. 

Wollenberg,  348,  447. 

Women,  Syphilis  in,  16  (see  Civilians). 

Wound  shock,  Bib.  909,  927,  961. 

Wounds  (brain),  914,  917,  918,  923,  924, 
926,  929,  931,  932,  934,  935,  943,  946, 
947,  950,  953.  958,  959,  9^8,  977,  980. 


Wounds  (skull,  head),  914,  915,  916,  917, 
918,  920,  922,  923,  924,  925,  926,  932, 
934,  935,  936,  939,  94i,  943,  944,  945, 
946,  949,  953,  954,  960,  962,  964,  965, 
967,  968,  969,  970,  971,  972,  974,  975, 
977,  978,  980,  981. 

Wright,  H.  P.,  589. 

Xanthochromia,  spinal  fluid,  282. 

X-Ray,  354,  480,  529,  531,  534,559,  561, 
565,  566,  594,  596,  602,  especially  606- 
608;  648,  725,  789,  798.     Bib.  913. 

Yealland,  723,  753,  786,  900. 
Yealland's    treatment    (see    Treatment, 

Shell-shock  neuroses,  Psychoelectric). 
Yes-no  test,  651,  770. 

Zange,  815. 

Zanger,  Cases  294,  482. 

Zeehandelaar,  348,  674,  790. 

Zoopsia,  164. 

Zum  Busch,  228. 


DATE  DUE 

CIC 

vJ/ 

- 

ffi "' 

')0^ 

f 

MAV  1  1 

2006 

DEMCO  38-296 

RY 

at  the 


COLUMBIA  UNIVERSITY  LIBRARIES 


0062118781 


